Excess mortality in Europe coincides with peaks of COVID-19, influenza and respiratory syncytial virus (RSV), November 2023 to February 2024

Since the end of November 2023, the European Mortality Monitoring Network (EuroMOMO) has observed excess mortality in Europe. During weeks 48 2023-6 2024, preliminary results show a substantially increased rate of 95.3 (95% CI:  91.7-98.9) excess all-cause deaths per 100,000 person-years for all ages. This excess mortality is seen in adults aged 45 years and older, and coincides with widespread presence of COVID-19, influenza and respiratory syncytial virus (RSV) observed in many European countries during the 2023/24 winter season.

[Evaluating the introduction of HIV pre-exposure prophylaxis as a benefit of statutory health insurance (EvE-PrEP) : Highly effective protection against HIV without an increase in sexually transmitted infections]

BACKGROUND

We investigated the impact of HIV pre-exposure prophylaxis (PrEP) as a new service of the statutory health insurance (SHI) on the incidence of HIV and other sexually transmitted infections (STIs) in Germany. In addition, PrEP needs and access barriers were analyzed.

METHODS

The following data were evaluated as part of the evaluation project: HIV and syphilis notification data and extended surveillance by the Robert Koch Institute (RKI), pharmacy prescription data, SHI routine data, PrEP use in HIV-specialty care centers, Checkpoint, the BRAHMS and PrApp studies, as well as a community board.

RESULTS

The majority of PrEP users were male (98-99%), primarily aged between 25-45 years, and predominantly of German nationality or origin (67-82%). The majority were men who have sex with men (99%). With regard to HIV infections, PrEP proved to be highly effective. There were only isolated cases of HIV infections (HIV incidence rate 0.08/100 person years); in most cases the suspected reason was low adherence. The incidences of chlamydia, gonorrhea, and syphilis did not increase but remained almost the same or even decreased. A need for information on PrEP for people in trans*/non-binary communities, sex workers, migrants, and drug users emerged. Needs-based services for target groups at increased risk of HIV are necessary.

DISCUSSION

PrEP proved to be a very effective HIV prevention method. The partly feared indirect negative influences on STI rates were not confirmed in this study. Due to the temporal overlap with the containment measures during the COVID-19 pandemic, a longer observation period would be desirable for a conclusive assessment.

SARS-CoV-2 Omicron variants BA.1 and BA.2 both show similarly reduced disease severity of COVID-19 compared to Delta, Germany, 2021 to 2022

German national surveillance data analysis shows that hospitalisation odds associated with Omicron lineage BA.1 or BA.2 infections are up to 80% lower than with Delta infection, primarily in ≥ 35-year-olds. Hospitalised vaccinated Omicron cases' proportions (2.3% for both lineages) seemed lower than those of the unvaccinated (4.4% for both lineages). Independent of vaccination status, the hospitalisation frequency among cases with Delta seemed nearly threefold higher (8.3%) than with Omicron (3.0% for both lineages), suggesting that Omicron inherently causes less severe disease.

SARS-CoV-2 variant B.1.1.7 susceptibility and infectiousness of children and adults deduced from investigations of childcare centre outbreaks, Germany, 2021

We investigated three SARS-CoV-2 variant B.1.1.7 childcare centre and related household outbreaks. Despite group cohorting, cases occurred in almost all groups, i.e. also among persons without close contact. Children’s secondary attack rates (SAR) were similar to adults (childcare centres: 23% vs 30%; p = 0.15; households: 32% vs 39%; p = 0.27); child- and adult-induced household outbreaks also led to similar SAR. With the advent of B.1.1.7, susceptibility and infectiousness of children and adults seem to converge. Public health measures should be revisited accordingly.

Increasing Number of Individuals Receiving Hepatitis B nucleos(t)ide Analogs Therapy in Germany, 2008-2019

Background: Germany is a low prevalence country for hepatitis B virus (HBV) infection with higher prevalence in vulnerable groups. The number of treated chronic hepatitis B (CHB) patients is unknown. We aimed to determine the number of CHB patients treated with nucleos(t)ide analogs (NUCs), the treatment costs within the statutory health insurance (SHI) in Germany and per patient per month. Methods: Data on pharmacy bills of NUCs to patients with SHI between 2008 and 2019 were purchased from Insight Health™ and described. Negative binomial regression was used for trend analysis. Results: Number of patients increased between 2008 and 2019 (4.9% per year) with little changes in treatment options. Overall prescription costs were increasing (6.7% per year on average) until the introduction of tenofovir and entecavir generics in 2017 after which costs decreased by 31% in 2019. Average therapy costs peaked at 498 Euro per patient per month in 2016 and decreased to 214 Euro in 2019. Prescriptions changed from 30 to 90 pills per pack over time. HBV therapy was prescribed to 97% by three medical specialist groups, mainly specialists in internal medicine (63%), followed by hospital-based outpatient clinics (20%) and general practitioners (15%). Contrary to guideline recommendation, adefovir was still prescribed after 2011 for 1-5% of patients albeit with decreasing tendency. Prescriptions per 100,000 inhabitants were highest in Berlin and Hamburg. Conclusion: Our data shows, that the number of treated CHB patients increased steadily, while NUC therapy costs decreased. We recommend continued testing and treatment for those eligible to prevent advanced liver disease and possibly decrease further transmission of HBV.

[Monitoring of COVID-19 by extending existing surveillance for acute respiratory infections]

Im Rahmen der nationalen Influenzapandemieplanung wurden in Deutschland neben dem Meldewesen gemäß Infektionsschutzgesetz (IfSG) weitere Überwachungssysteme etabliert. Ziel dieser Systeme sind die Beschreibung, Analyse und Bewertung der Situation bei akuten respiratorischen Erkrankungen (ARE), die Identifikation der hauptsächlich zirkulierenden Atemwegserreger und die Beschreibung des zeitlichen Verlaufs. Seit Beginn der COVID-19-Pandemie wurden die Systeme erweitert, um auch Infektionen mit SARS-CoV‑2 erfassen zu können.

In diesem Beitrag werden drei verschiedene Surveillance-Systeme für ARE vorgestellt: GrippeWeb, die Arbeitsgemeinschaft Influenza mit dem SEED^ARE-Modul (Sentinel zur elektronischen Erfassung von Diagnosecodes) und das Krankenhaus-Sentinel ICOSARI (ICD-10-code-basierte Krankenhaus-Surveillance schwerer akuter respiratorischer Infektionen). Mit diesen Systemen können ARE auf Bevölkerungsebene, im ambulanten und im stationären Bereich überwacht werden. Zusammen mit dem Monitoring der Mortalität liefern sie wichtige Hinweise zur Häufigkeit verschieden schwerer Krankheitsverläufe in der Bevölkerung. Um die Systeme für SARS-CoV‑2 zu erweitern, waren nur wenige Anpassungen notwendig.

Da die Falldefinitionen für ARE nicht geändert wurden, können in den beschriebenen Systemen historische Zeitreihen zum Vergleich herangezogen werden. Alle Systeme sind so aufgebaut, dass stabile und etablierte Bezugsgrößen für die Berechnung von wöchentlichen Anteilen und Raten zur Verfügung stehen. Dies ist eine wichtige Ergänzung zum Meldewesen gemäß IfSG, welches stark von Testkapazitäten und -strategien sowie veränderten Falldefinitionen abhängt. Die Surveillance-Systeme haben sich in der COVID-19-Pandemie auch im internationalen Vergleich als praktikabel und effizient erwiesen.

Heat-Related Mortality

BACKGROUND

As a consequence of global warming, heat waves are expected to become more frequent, more intense, and longer. The elderly and persons with chronic diseases are especially vulnerable to health problems due to heat. This article is devoted to the question of the extent to which the effects of heat waves in Germany are changing over time, and whether preventive health measures are working.

METHODS

We use a statistical model to quantify the effect of high mean temperatures on mortality. Within this model, different exposure-response curves for the three temporal intervals 1992-2000, 2001-2010, and 2011-2017 are estimated. Attention is also paid to the delayed effect on mortality of high mean temperatures in the preceding week.

RESULTS

Our analysis reveals a clear, systematic association of the mean temperature in the current week, as well as the mean temperature in the preceding week, with weekly mortality. This association is more pronounced for higher age groups and decreases over the years under analysis, with the exception of a relatively weak effect of heat in southern Germany in 1992-2000. The strongest effects were related to the heat waves in 1994 and 2003, with approximately 10 200 and 9600 fatalities, respectively. Approximately 7800 fatalities were estimated for the summer of 2006, and 4700 and 5200 for 2010 and 2015, respectively.

CONCLUSION

In Germany, as elsewhere, climate change has been causing more frequent, more intense, and longer periods of heat in the summer. The harmful effect of heat on health is reduced by adaptive processes, presumably including successful preventive measures. Such measures should be extended in the future, and perhaps complemented by other measures in order to further diminish the effect of heat on mortality .

Real-time monitoring shows substantial excess all-cause mortality during second wave of COVID-19 in Europe, October to December 2020

The European monitoring of excess mortality for public health action (EuroMOMO) network monitors weekly excess all-cause mortality in 27 European countries or subnational areas. During the first wave of the coronavirus disease (COVID-19) pandemic in Europe in spring 2020, several countries experienced extraordinarily high levels of excess mortality. Europe is currently seeing another upsurge in COVID-19 cases, and EuroMOMO is again witnessing a substantial excess all-cause mortality attributable to COVID-19.

[Prevalence of patients with HIV receiving outpatient medical care in Germany-an analysis based on secondary data]

BACKGROUND

The Robert Koch Institute (RKI) annually publishes an estimate of the number of new HIV diagnoses and the total number of people diagnosed with HIV in Germany. So far, only medication prescription data have served as secondary data as a basis for such estimates.

OBJECTIVES

In this study, we used billing data from the outpatient sector to estimate the number of patients with newly diagnosed HIV, the overall number of patients with HIV, and the HIV test rates in those with statutory health insurance in Germany.

MATERIALS AND METHODS

We analyzed billing data from the outpatient sector for all persons covered by statutory health insurance between 2009 and 2018. We designed annual cohorts of patient for the years 2011 to 2017 and analyzed the number of HIV diagnoses, the number of HIV-related care services, and HIV testing rates.

RESULTS

Every year, about 6000 new patients with HIV are treated in outpatient care. The total number of patients with HIV in 2011 was about 59,300 (0.106%), which increased to 80,800 (0.141%) in 2017. The average increase in the total number of patients per year of about 3600 was significantly below the estimated number of newly treated patients for each year.

CONCLUSION

The results may provide an indication of patients receiving HIV care in the outpatient sector. The secondary data provide the possibility of developing another epidemiological data source for population-based representation of the administrative prevalence of HIV. To clarify over-representation, there is a need for further research on patients who are using outpatient care for the first time.

Invasive Haemophilus influenzae Infections in Germany After the Introduction of Routine Childhood Immunization, 2001-2016

Background

Haemophilus influenzae (Hi) serotype b (Hib) vaccination was introduced in Germany in 1990. This study presents a comprehensive overview on the burden of invasive Hi infections for 2001–2016, including serotype distribution and ampicillin resistance.

Methods

Nationwide data from statutory disease surveillance (2001–2016) were linked with laboratory surveillance data (2009–2016). Besides descriptive epidemiology, statistical analyses included multiple imputation to estimate secular trends.

Results

In 2001–2016, 4044 invasive Hi infections were reported. The mean incidence was 3.0 per million inhabitants, higher in males (3.2 vs 2.9 in females) and in the age groups <1 year (15.2) and ≥80 years (15.5). Nontypeable Hi (NTHi) caused 81% (n = 1545) of cases in 2009–2016. Of capsulated cases, 69% were serotype f and 17% serotype b. Of Hib cases eligible for vaccination, 10% (3/29) were fully vaccinated. For 2009–2016, significant increasing trends were observed for NTHi and Hif infections in the age groups <5 years and ≥60 years and for ampicillin resistance in NTHi.

Conclusions

This is one of the most comprehensive Hi data analyses since the introduction of Hib vaccines. NTHi and Hif cause an increasing disease burden among elderly patients and infants. Ampicillin resistance in NTHi must be considered in the treatment of invasive Hi infections.

Excess all-cause mortality during the COVID-19 pandemic in Europe - preliminary pooled estimates from the EuroMOMO network, March to April 2020

A remarkable excess mortality has coincided with the COVID-19 pandemic in Europe. We present preliminary pooled estimates of all-cause mortality for 24 European countries/federal states participating in the European monitoring of excess mortality for public health action (EuroMOMO) network, for the period March–April 2020. Excess mortality particularly affected  ≥ 65 year olds (91% of all excess deaths), but also 45–64 (8%) and 15–44 year olds (1%). No excess mortality was observed in 0–14 year olds.

Prevalence of hepatitis C in the adult population of Bulgaria: a pilot study

Objective

This study piloted a European technical protocol for conducting chronic hepatitis C prevalence surveys in the general population. The pilot study took place in the Bulgarian city of Stara Zagora in 2018, and results of setting up, conducting and evaluating the survey are presented.

Results

A probability-based sample of the general adult population was drawn from the local population registry, stratified by age and sex. A sample size of 999 was calculated, and accounting for 50% non-response, 1998 registered invitation letters were sent. Venous blood samples and questionnaire data were collected by the Regional Health Inspectorate in Stara Zagora. Blood samples were tested for anti-HCV, and if reactive for RNA. 252 (21.6%) of the participants were included in the study. Mean age and sex distribution differed between the participants (55.9 years, 60.3% females) and the total sample (48.9 years, 53.4%). The weighted chronic HCV prevalence among participants was 0.9% [95% CI 0.2–4.2%]. The approach of only sending registered letters contributed to a low response rate, and more efforts are needed to reduce non-response, especially among men and younger age groups. Results of the evaluation were integrated in the final technical protocol.

Eliminating Hepatitis C Virus Among Human Immunodeficiency Virus-Infected Men Who Have Sex With Men in Berlin: A Modeling Analysis

BACKGROUND

Despite high hepatitis C virus (HCV) treatment rates, HCV incidence among human immunodeficiency virus (HIV)-infected men who have sex with men (HIV-infected MSM) in Germany rose before HCV direct-acting antivirals (DAAs). We model what intervention can achieve the World Health Organization (WHO) elimination target of an 80% reduction in HCV incidence by 2030 among HIV-infected MSM in Berlin.

METHODS

An HCV transmission model among HIV-diagnosed MSM was calibrated to Berlin (rising HCV incidence and high rates of HCV testing and treatment). We modeled the HCV incidence among HIV-diagnosed MSM in Berlin until 2030 (relative to 2015 WHO baseline) under scenarios of DAA scale-up with or without behavior change (among HIV-diagnosed MSM and/or all MSM).

RESULTS

Continuing current treatment rates will marginally reduce the HCV incidence among HIV-diagnosed MSM in Berlin by 2030. Scaling up DAA treatment rates, beginning in 2018, to 100% of newly diagnosed HCV infections within 3 months of diagnosis and 25% each year of previously diagnosed and untreated HCV infections could reduce the HCV incidence by 61% (95% confidence interval, 55.4%-66.7%) by 2030. The WHO target would likely be achieved by combining DAA scale-up with a 40% reduction in HCV transmission among HIV-diagnosed MSM and a 20% reduction among HIV-undiagnosed or HIV-uninfected MSM.

DISCUSSION

HCV elimination among HIV-infected MSM in Berlin likely requires combining DAA scale-up with moderately effective behavioral interventions to reduce risk among all MSM.

[Estimation of heat-related deaths in Germany between 2001 and 2015]

BACKGROUND

During the summers of 2003 and 2015, heat was found to be the cause of a substantial number of deaths in Germany. Until now, estimates for the total number of heat-related deaths were only available regionally in Germany. For the summer of 2003, an analysis for Baden-Württemberg was extrapolated to the whole of Germany.

OBJECTIVES

Our analysis tries to prove a stable statistical relationship between heat and mortality and to use this to quantify the number of heat-related deaths in Germany between the years 2001 and 2015.

MATERIALS AND METHODS

By fitting a nonlinear statistical model, we estimated exposure-response curves that describe the influence of heat on the mortality rate. The performance of different indicators for heat stress was compared.

RESULTS

The comparison of the different indicators for heat showed that the weekly mean temperature was most useful to explain the course of the weekly mortality during the summer. The relation between mortality rate and weekly mean temperature varied between age groups and regions in Germany (north, middle, south). The age groups (75-84) and (85+) were most affected by heat. The highest number of heat-related deaths was 7600 (95% CI 5500-9900), found for the summer 2003, followed by 6200 (4000; 8000) in the summer 2006 and 6100 (4000; 8300) in the summer 2015.

CONCLUSIONS

We could show that even in weekly data on mortality, a clear influence of heat could be identified. A national surveillance of mortality that allows real-time monitoring would be desirable.

[Sexually transmitted infections in Germany : The current epidemiological situation]

Sexually transmitted infections (STIs) can impair sexual health. Surveillance and study data were used to provide an overview over STIs in Germany. We estimated 3900 new HIV diagnoses in 2015. Of newly diagnosed infections, 57% were attributed to men who have sex with men (MSM). It was further estimated that there were 3200 new HIV infections and 84,700 people living with HIV in 2015. A total of 6834 syphilis infections were recorded in 2015, which corresponds to an increase of 149% since 2009. The incidence in men was 16-times higher than in women. Of syphilis infections, 85% could be attributed to MSM. Antimicrobial resistance of gonococci against the broad-spectrum antibiotic cefixime decreased between 2014 and 2016 after a change of therapy guidelines and remained stable on a low level regarding the antibiotic ceftriaxone. After an increase of resistance against the antibiotic azithromycin to 11.3% in 2015, we observed a decreasing trend in 2016. Between 2013 and 2015, 2,355,336 chlamydia tests were reported through the chlamydia sentinel network. Of these, 92.5% of samples were from women. Uptake for screening for women <25 years was 11.3% in 2015, with 5.0% positive chlamydia tests. In a cross-sectional study among women aged 20-25 years, a prevalence of human papilloma virus (HPV) of 38.1% was observed. A total of 30.5% of 15-year-old women were vaccinated against HPV in 2014. Data suggest that STIs represent a high burden of disease. Knowledge of STI prevention should be improved by targeted education campaigns. Extending existing offers for counselling and testing through cooperation between different health sectors would improve early diagnosis and treatment of STIs.

Evaluation of a BioRad Avidity assay for identification of recent HIV-1 infections using dried serum or plasma spots

Serological methods to differentiate between recently acquired and established HIV-1 infections are a useful tool in the HIV-surveillance to characterize the epidemic, identify groups at risk and assess HIV-preventive interventions. Therefore, an avidity-based, modified BioRad Genscreen™ HIV-1/2 assay (BRA_EUR) was evaluated according to the avidity-based, modified BioRad HIV-1/2 Plus O protocol (BRA_USA). Overall, 692 well defined samples (82.5% B and 17.5% non-B subtypes) from recent (<180 days, n = 239), intermediate (181-364 days, n = 35) or long term infections (≥365 days, n = 419) were used to determine a 'mean duration of recent infection' (MDRI), a 'median DRI' (MdDRI), the false recent rate (FRR), and concordance between the BRAs and the Sedia BED HIV-1 Capture enzyme immunoassay (BED). The optimal avidity index cut-off was determined to be 70% resulting in an MDRI of 233 days (95% IQR: 174-351) and an MdDRI of 171 days (95% IQR: 142-212). Concordance with the BRA_USA was high with 96.4%. The FRR of 6.0% as well as the MdDRI are similar to the BED (8.4%; 170 (139-214) days). Therefore, the BRA_EUR is a suitable alternative to replace the BED and trend analysis will be feasible after minimal adjustments for the MdDRI and the MDRI.

Trends in human immunodeficiency virus diagnoses among men who have sex with men in North America, Western Europe, and Australia, 2000-2014

PURPOSE

The aim of the article was to investigate recent trends in human immunodeficiency virus (HIV) diagnosis rates among men who have sex with men (MSM) in high-income countries in North America, Western Europe, and Australia.

METHODS

Data on annual rates of HIV diagnoses among MSM aged 15 to 65 years from 2000 to 2014 were collected from 13 high-income countries. Joinpoint regression software was used to empirically determine country-specific trend periods. Trends in HIV diagnosis rates and in the proportion of diagnoses occurring in young MSM aged 15 to 24 years were analyzed using Poisson regression and log-binomial regression, respectively.

RESULTS

Six countries experienced an increasing trend from 2000 to 2007-08 followed by either a stable or declining trend through 2014. Five countries had recently increasing trends, and two countries had one stable trend from 2000 to 2014. All 13 countries experienced increases in the proportion of diagnoses occurring in young MSM.

CONCLUSIONS

Since 2008, half of the 13 high-income countries examined experienced stable or decreasing trends. Still, some countries continue to experience increasing HIV trends, and young MSM are increasingly represented among new diagnoses. Efforts to support early sexual health promotion, reduce barriers to pre-exposure prophylaxis, and improve care engagement for young MSM are critical to addressing current HIV trends.

Not again! Effect of previous test results, age group and reason for testing on (re-)infection with Chlamydia trachomatis in Germany

Background

Infection with Chlamydia trachomatis (Ct) is the most commonly reported sexually transmitted infection in Europe. In Germany, Ct screening is offered free of charge to pregnant women since 1995 and to women < 25 years of age since 2008. For symptomatic individuals, testing is covered by statutory health insurance. Study results have shown that repeat Ct infection occurs in 10–20% of previously infected women and men. Our aim was to describe persons tested for Ct and to investigate the determinants of (repeat) Ct infection in women and men in Germany.

Methods

We analysed Ct test results from men and women tested between 2008 and 2014 in laboratories participating in the German Chlamydia trachomatis Laboratory Sentinel surveillance. Reinfection was defined as at least 2 positive laboratory tests within more than 30 days. We performed logistic regression stratified by sex and, for women, reason for testing to determine the effect of previous test results and age group on subsequent test results.

Results

In total, 2,574,635 Ct tests could be attributed to 1,815,494 women and 123,033 men. 5% of women and 14% of men tested positive at least once. 15–19- and 20–24-year-old women tested positive at least once respectively in 6.8 and 6.0%, while men respectively in 16.6 and 21.2%. Altogether, 23.1% of tested women and 11.9% of tested men were tested repeatedly between 2008 and 2014. Among those who previously tested positive, reinfection occurred in 2.0% of women and 6.6% of men. Likelihood to be tested Ct positive was higher in women and men with a positive Ct test in the past compared to previously tested Ct negative, odds ratios 4.7 and 2.6 (p < 0.01) respectively. Odds ratios ranged by age group and test reason.

Conclusion

A history of Ct infection increased the likelihood of infection with Ct in women and men taking into account the result of the previous test. Health education, safer sex and treatment of partners are necessary for women and men who have tested positive to prevent reinfection and complications and to interrupt the chain of transmission. To identify potential reinfection repeat testing after treatment should be performed.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3323-2) contains supplementary material, which is available to authorized users.

Risk behaviours and viral infections among drug injecting migrants from the former Soviet Union in Germany: Results from the DRUCK-study

BACKGROUND

High prevalence of drug use and injection-related risk behaviours have been reported among former Soviet Union (FSU)-migrants. To investigate hepatitis C (HCV) and HIV seroprevalence and related risk behaviours in this subgroup in Germany, we compared first generation FSU-migrants and native Germans using data from a sero-behavioural survey of people who inject drugs (PWID).

METHODS

Current injectors were recruited using respondent-driven sampling in eight German cities in 2011-2014. Questionnaire-based interviews were conducted and dried blood spots collected and tested for anti-HCV, HCV-RNA, and anti-HIV1/2. Descriptive and multivariable analyses (MVA) were performed.

RESULTS

A total of 208 FSU-born and 1318 native German PWID were included in the analysis. FSU-migrants were younger than Germans (median age: 33 vs. 39 years), and more often male (83.1% vs. 75.9%, p = 0.022). HCV seroprevalence was 74.5% in FSU-migrants vs. 64.6% in Germans (p = 0.006), HIV seroprevalence was 5.8% and 4.6%, respectively (p = 0.443). The proportion of FSU-migrants reporting injecting-related risk behaviours was higher than among Germans: injecting daily (39.4% vs. 30.2%, p = 0.015), with friends (39.2% vs. 31.2%, p = 0.038), cocaine (32.7% vs. 23.8%, p = 0.044), more than one drug (18.2% vs. 9.6%, p = 0.006), and sharing filters/cookers (35.5% vs. 28.0%, p = 0.045). No statistically significant differences were observed in HIV/HCV testing rates (range: 50.7%-65.6%), opioid substitution treatment (43.9% vs. 50.5%), and access to clean needles/syringes (89.8% vs. 90.3%). In MVA, risk for HCV-infection was increased in male FSU-migrants compared to German males (OR 3.32, p = 0.006), no difference was identified between female FSU-migrants and German females (OR: 0.83, p = 0.633).

CONCLUSION

Male FSU-migrants were at highest risk of being HCV infected. Therefore, targeted actions are needed to ensure access and acceptance of harm reduction measures, including HCV-testing and -treatment for this subpopulation of PWID.

Assessing varicella vaccine effectiveness and its influencing factors using health insurance claims data, Germany, 2006 to 2015

In Germany, routine childhood varicella vaccination was implemented in 2004 with two doses recommended since 2009. We used an immunisation information system based on countrywide health insurance claims data to analyse vaccine effectiveness (VE) and factors influencing VE. We applied proportional hazard models to estimate VE under various conditions and compared the risk of acquiring varicella among unvaccinated children in regions with high vs low vaccination coverage (VC). Among 1.4 million children we identified 29,404 varicella cases over a maximum follow-up of 8 years post-vaccination. One-dose VE was 81.9% (95% confidence interval (CI): 81.4–82.5), two-dose VE 94.4% (95% CI: 94.2–94.6). With dose one given 1–27 days after measles-containing vaccine (MCV), one-dose VE was 32.2% (95% CI: 10.4–48.6), two-dose VE 92.8% (95% CI: 84.8–96.6). VE was not associated with age at vaccination (11–14 vs ≥ 15 months), time since vaccination, or vaccine type. Unvaccinated children had a twofold higher risk of acquiring varicella in low VC regions. Our system generated valuable data, showing that two-dose varicella vaccination provides good protection for at least 8 years. Unvaccinated children benefit from herd effects. When the first varicella vaccine dose is given shortly after MCV, a second dose is essential.

CD4-cell counts and presence of AIDS in HIV-positive patients entering specialized care-a comparison of migrant groups in the German ClinSurv HIV Cohort Study, 1999-2013

Background

Although early presentation to HIV-care is essential to ensure timely initiation of antiretroviral therapy, recent studies have shown that especially migrants present to HIV-care at a later stage of HIV-infection. Currently, thirty percent of all newly diagnosed HIV cases in Germany originate from abroad. So far it is unknown, which specific migrant groups in Germany are particularly at risk for late presentation to HIV-care.

Methods

We used data from the Clinical Surveillance of HIV Disease (ClinSurv) cohort, a multi-centre observational cohort (01/01/1999 and 31/07/2013) and included treatment-naïve patients with valid information on country of origin and date of enrolment. Migrants were patients with country of origin outside Germany. We compared time trends for percentage of AIDS (CDC Stage C) and mean CD4-count at enrolment between migrants from Western Europe (WE), Central Europe (CE), Eastern Europe (EE), Sub-Saharan Africa (SSA), South East Asia (SEA) and non-migrants using multivariable regressions. Male non-migrants with mean age of 38-years constituted the reference group.

Results

In total, 10,211 patients fulfilled the inclusion criteria, of which 2784 were migrants (SSA: 42%, CE: 17%, WE: 11%, EE: 10%, SEA: 9%). The percentage of patients with AIDS at enrolment was higher in SSA (Odds Ratio (OR)_SSA: 1.44, 95%-confidence interval (95%-CI):1.12–1.84) and SEA-migrants (OR_SEA:2.16, 95%-CI:1.43–3.27). In addition, female SEA-migrants, were more likely to present with AIDS than their male counterparts (OR:2.22, 95%-CI:1.18–4.17). Mean CD4-count at enrolment was lower for SSA- (Mean CD4-count ratio (IRR):0.72; 95%-CI:0.64-0.82) and SEA-migrants (IRR:0.62, 95%-CI:0.49-0.78). Over time, it increased in non-migrants and CE-migrants (by 1 and 3%/year, respectively), whereas no increase was seen for SEA and SSA.

Conclusions

SSA and SEA-migrants in Germany present to HIV-care at a later stage of HIV infection than non-migrants. Additionally, previous research found a higher risk for late HIV-testing for migrants. Collecting information about the arrival date of migrants in Germany in the HIV notification system would help to understand to which extent these problems could be tackled in Germany. Moreover, participatory approaches for HIV-testing and care as well as research regarding knowledge, behaviour and attitudes towards these topics for SSA and SEA migrants should be expanded.

Estimation of influenza-attributable medically attended acute respiratory illness by influenza type/subtype and age, Germany, 2001/02-2014/15

Background

The total burden of influenza in primary care is difficult to assess. The case definition of medically attended “acute respiratory infection” (MAARI) in the German physician sentinel is sensitive; however, it requires modelling techniques to derive estimates of disease attributable to influenza. We aimed to examine the impact of type/subtype and age.

Methods

Data on MAARI and virological results of respiratory samples (virological sentinel) were available from 2001/02 until 2014/15. We constructed a generalized additive regression model for the periodic baseline and the secular trend. The weekly number of influenza‐positive samples represented influenza activity. In a second step, we distributed the estimated influenza‐attributable MAARI (iMAARI) according to the distribution of types/subtypes in the virological sentinel.

Results

Season‐specific iMAARI ranged from 0.7% to 8.9% of the population. Seasons with the strongest impact were dominated by A(H3), and iMAARI attack rate of the pandemic 2009 (A(H1)pdm09) was 4.9%. Regularly the two child age groups (0‐4 and 5‐14 years old) had the highest iMAARI attack rates reaching frequently levels up to 15%‐20%. Influenza B affected the age group of 5‐ to 14‐year‐old children substantially more than any other age group. Sensitivity analyses demonstrated both comparability and stability of the model.

Conclusion

We constructed a model that is well suited to estimate the substantial impact of influenza on the primary care sector. A(H3) causes overall the greatest number of iMAARI, and influenza B has the greatest impact on school‐age children. The model may incorporate time series of other pathogens as they become available.

Determinants of HIV, viral hepatitis and STI prevention needs among African migrants in Germany; a cross-sectional survey on knowledge, attitudes, behaviors and practices

BACKGROUND

Migrants from sub-Saharan Africa (MisSA) are a relevant sub-group for HIV-transmission in Germany. A total of 10-15 % of all newly diagnosed cases are MisSA, and approximately one third acquired HIV in Germany. There is limited information on knowledge, attitudes, behaviors and practices (KABP) regarding sexual health in African communities residing in Germany.

METHODS

From October-December 2013 we conducted a cross-sectional survey on KABP regarding HIV, viral hepatitis (HEP), and sexually transmitted infections (STI) among MisSA in Hamburg as a community-based participatory research project to identify knowledge gaps, sexual risk behavior regarding HIV/HEP/STI, HIV/STI-testing history and attitudes toward people living with HIV (PLWH). Trained peer researchers recruited participants through outreach. Questionnaires in German, English or French were either administered face-to-face or self-completed. Questions on knowledge about HIV/HEP/STI presented true statements; participants were asked if they knew the information before. To detect differences in sub-groups, unadjusted odds ratios (OR) were calculated, and a multivariate analysis for knowledge on HIV/HEP/STI was performed.

RESULTS

The final sample included 569 participants of whom 57 % were men. Most participants originated from Western and Central sub-Saharan Africa. Median time living in Germany was 6 years. Overall, 28 % had a university degree and 54 % reported a good level of German language. Over 80 % knew the risks for HIV transmission. A total of 44 % of respondents wrongly assumed that an HIV-diagnosis might lead to deportation and 64 % were not aware of the free and anonymous local HIV/STI-testing service. The proportion of participants with knowledge of presented facts on HEP varied from 40-58 %. The respective proportion on STI was 28-68 % and better among women compared to men (44 % vs. 54 %; OR = 1.45; 95 % CI 1.22-1.74). Men reported more often casual sex partners than women (43 % vs. 23 %; OR = 2.6; 95 % CI 1.7-4.0), and more frequently a previous STI (58 % vs. 39 %; OR = 2.1; 95 % CI 1.1-4.1). Overall, 16 % of women reported a history of sexual violence. The majority of respondents (75 %) reported that they would treat PLWH like any other person.

CONCLUSION

Study participants demonstrated good knowledge on HIV-transmission but knowledge gaps regarding HIV/STI-testing services, HEP and STI. This calls for targeted interventions providing more information about these topics in African communities in Hamburg and possibly also elsewhere.

HIV-prevalence in tuberculosis patients in Germany, 2002-2009: an estimation based on HIV and tuberculosis surveillance data

Tuberculosis (TB) and HIV comorbidity is a major challenge in TB prevention and control but difficult to assess in Germany as in other countries, where data confidentiality precludes notifying the HIV status of TB patients. We aimed to estimate the HIV-prevalence in TB patients in Germany, 2002-2009, and to characterize the HIV/TB patients demographically. Data from the long-term observational open multicentre cohort ClinSurv HIV were used to identify incident TB in HIV-positive individuals. We assessed the cohort's coverage for the nationwide HIV-positive population by contrasting ClinSurv HIV patients under antiretroviral therapy (ART) with national HIV patient numbers derived from ART prescriptions (data by Insight Health; available for 2006-2009). The HIV-prevalence in TB patients was calculated as the number of HIV/TB cases projected for Germany over all culture-positive TB notifications. From 2002 to 2009, 298 of 15,531 HIV-positive patients enrolled in the ClinSurv HIV cohort were diagnosed with TB. A 21% cohort coverage was determined. The annual estimates of the HIV-prevalence in TB patients were on average 4.5% and ranged from 3.5% (95%CI 2.3-5.1%) in 2007 to 6.6% (95%CI 5.0-8.5%) in 2005. The most recent estimate for 2009 was 4.0% (95%CI 2.6-5.9%). The 298 HIV/TB patients were characterized by a male-to-female ratio of 2.1, by a median age of 38 years at TB diagnosis, and by 59% of the patients having a foreign origin, mainly from Subsahara Africa. We provide, to our knowledge, the first estimate of the HIV-prevalence in TB patients for Germany by joint evaluation of anonymous HIV and TB surveillance data sources. The identified level of HIV in TB patients approximates available surveillance data from neighbouring countries and indicates a non-negligible HIV/TB burden in Germany. Our estimation approach is valuable for epidemiological monitoring of HIV/TB within the current legal frameworks.

Impact of rotavirus vaccination in regions with low and moderate vaccine uptake in Germany

In Germany, routine RV-vaccination is not adopted into the national immunization schedule as of 2012. Because RV-vaccines were already on the market since 2006, in 2010 a moderate (58%) and low (22%) vaccine uptake was observed in the 5 eastern federal states (EFS) and the 11 western federal states (WFS), respectively. To assess the impact of RV-vaccination, we compared the incidence rates (IR) of RV-related hospitalizations before (2004‒2006) and in seasons after (2008/09-2010/11) RV-vaccine introduction in Germany by utilizing data from the national mandatory disease reporting system. In the EFS, the IR was significantly reduced in age-groups < 18 mo in 2008/09 and in age-groups < 24 mo in 2009/10-2010/11. In the WFS an IR-reduction was observed only in age-groups < 12 mo in 2008/09 and in age-groups < 18 mo in 2009/10-2010/11. Overall IR-reduction in age-groups < 24 mo comparing 2008-11 with 2004-06 was 36% and 25% in EFS and WFS, respectively. In addition, we computed IR-ratios (IRR) in the seasons after mid-2006 with negative binomial regression. The effect of vaccination was independent from the geographic region. Vaccination was associated with a significant reduction in RV-related hospitalizations in the age-groups 6-23 mo. Most prominently, vaccination of 50% of infants led to an estimated decrease in age group 6-11 mo by 42%. No significant reduction was observed in age-groups ≥ 24 mo. In conclusion, in the German setting with low to moderate vaccine uptake, RV-related hospitalization incidence decreased substantially depending on the achieved vaccination coverage, but only in the first two years of life.

Timeliness of surveillance during outbreak of Shiga Toxin-producing Escherichia coli infection, Germany, 2011

In the context of a large outbreak of Shiga toxin–producing Escherichia coli O104:H4 in Germany, we quantified the timeliness of the German surveillance system for hemolytic uremic syndrome and Shiga toxin–producing E. coli notifiable diseases during 2003–2011. Although reporting occurred faster than required by law, potential for improvement exists at all levels of the information chain.

Trouble with bleeding: risk factors for acute hepatitis C among HIV-positive gay men from Germany--a case-control study

OBJECTIVES

To identify risk factors for hepatitis C among HIV-positive men who have sex with men (MSM), focusing on potential sexual, nosocomial, and other non-sexual determinants.

BACKGROUND

Outbreaks of hepatitis C virus (HCV) infections among HIV-positive MSM have been reported by clinicians in post-industrialized countries since 2000. The sexual acquisition of HCV by gay men who are HIV positive is not, however, fully understood.

METHODS

Between 2006 and 2008, a case-control study was embedded into a behavioural survey of MSM in Germany. Cases were HIV-positive and acutely HCV-co-infected, with no history of injection drug use. HIV-positive MSM without known HCV infection, matched for age group, served as controls. The HCV-serostatus of controls was assessed by serological testing of dried blood specimens. Univariable and multivariable regression analyses were used to identify factors independently associated with HCV-co-infection.

RESULTS

34 cases and 67 controls were included. Sex-associated rectal bleeding, receptive fisting and snorting cocaine/amphetamines, combined with group sex, were independently associated with case status. Among cases, surgical interventions overlapped with sex-associated rectal bleeding.

CONCLUSIONS

Sexual practices leading to rectal bleeding, and snorting drugs in settings of increased HCV-prevalence are risk factors for acute hepatitis C. We suggest that sharing snorting equipment as well as sharing sexual partners might be modes of sexual transmission. Condoms and gloves may not provide adequate protection if they are contaminated with blood. Public health interventions for HIV-positive gay men should address the role of blood in sexual risk behaviour. Further research is needed into the interplay of proctosurgery and sex-associated rectal bleeding.