Expression of the Tumor-Associated Glycoproteins Mca, Ca 125 and Bw 495/36-P in Epithelial Tumors of the Kidney and the Urinary Bladder

The differential expression of the tumor-associated glycoproteins MCA, CA 125 and BW 495/36-P was investigated in 11 renal cell carcinomas and 11 urinary bladder carcinomas and compared with their expression in non-neoplastic tissue preparations from the kidney (n = 9) and urinary bladder (n = 12). The glycoproteins were demonstrated immunohistologically in frozen sections and additionally, in some cases, in paraffin sections. MCA and BW 495/36-P positive cells were present in all preparations except for a grade I transitional cell carcinoma of the bladder, in which no MCA-expression could be detected. In the non-neoplastic renal tissue mainly the cells of the distal tubuli were stained by the antibodies against these two glycoproteins. Carcinoma cells of the kidney and of the urinary bladder showed an increased expression of both epitopes.

CA 125, in comparison, was strongly expressed in 3 of the 11 urinary bladder carcinomas investigated but could only be shown in a few cells of a single renal cell carcinoma. Normal renal tissue showed no and the urinary bladder only very isolated CA 125 positive epithelial cells. Apart from this distribution, strong staining of the connective tissue fibers with CA 125 antibody was seen in all paraffin sections, but not in the frozen sections. This leads to the supposition that in these structures there is a CA 125 cryptantigen. The consistent expression of MCA as well as the virtual lack of CA 125 in the renal cell carcinomas are in contrast with our previous serological results, in which patients with metastatic renal cell carcinomas showed increased CA 125 in approx. 50% of cases whereas only approx. 20% had increased MCA serum levels.

Immunocytochemical determination of the tumor-associated glycoproteins MCA, CA 125 and BW 495/36-P in urine of patients with epithelial tumors of the kidney and urinary bladder

Pre-operative and, in some cases, post-operative urine samples from 29 patients with renal cell or urinary bladder carcinoma were compared to samples from 24 healthy persons and 10 patients with nephrolithiasis and 9 patients with other benign disorders of the efferent urinary tract. The specimens were examined for the presence of MCA, CA 125 and BW 495/36-P expressing epithelial cells. The urine concentrations of the soluble antigens MCA and CA 125 were determined simultaneously in urine samples from 35 patients with renal cell or urinary bladder carcinoma, 10 patients with cystitis and 30 healthy individuals.

MCA and BW 495/36-P expressing epithelial cells were significantly increased in all pre-operative urine samples of the tumor patients compared to the group of healthy persons. This increase was also seen with CA 125-positive cells in patients with bladder carcinoma, not however in patients with renal cell carcinoma. BW 495/36-P positive cells were also found in both groups of tumor patients in greater numbers than in the patients with nephrolithiasis or other benign urinary tract disorders. Based on a specificity of 97% when compared to the control urine samples, the cytological determination of the antigens MCA, CA 125 and BW 495/36-P in urinary tract cells of all tumor patients revealed a sensitivity of 48%, 33% and 79% as well as a positive predictive value of 92%, 89% and 95%, respectively. The sensitivity of CA 125 increased to 67% upon isolated analysis of patients with bladder carcinoma.

The majority of labelled cells were not identifiable as tumor cells morphologically and appeared as normal transitional epithelial cells.

The urinary concentration of soluble MCA was greatest in healthy patients whereas the concentration of CA 125 was increased in patients with bladder carcinoma.

Our results indicate that especially the determination of BW 495/36-P expressing epithelial cells could be a helpful supplement to the cytological examination of urinary epithelium with regard to renal cell and bladder carcinoma. Determination of CA 125-positive cells appears to be of diagnostic relevance only in cases of suspected bladder carcinoma.

Trastuzumab without chemotherapy in the adjuvant treatment of breast cancer: subgroup results from a large observational study

Background

The topic of trastuzumab therapy without chemotherapy in early breast cancer (EBC) has been repeatedly discussed at international consensus meetings, but is compromised by the lack of solid evidence from clinical studies.

Methods

An observational study database of patients with EBC receiving trastuzumab-containing (neo)adjuvant therapy was screened to identify those patients who did not receive cytostatic agents.

Results

Of 3935 patients, 232 (6%) were identified who received no chemotherapy, being characterized by older age, worse performance status, and/or less aggressive histology. Relapse-free survival in this cohort was 84% (95% confidence interval [CI] 78–89%) at 3 years and 80% (95% CI 74–87%) at 5 years. However, these rates were significantly worse than those in the group of patients who received chemotherapy (hazard ratio 1.49; 95% CI 1.06–2.09; P = 0.022). A similar pattern was observed for overall survival, with marginally non-significant inferiority in the group receiving no chemotherapy (hazard ratio 1.56; 95% CI 1.00–2.44; P = 0.052). Survival rates in patients receiving no chemotherapy were 93% (95% CI 88–97%) and 87% (95% CI 81–93%) at 3 and 5 years, respectively. These findings were confirmed by a propensity score analysis accounting for selection bias.

Conclusions

Trastuzumab plus chemotherapy should remain the preferred option in all patients with HER2-positive EBC with an indication for adjuvant treatment. However, a limited proportion of patients will need an alternative treatment approach, either because of contraindications or the patient’s preference. In these selected patients, trastuzumab monotherapy, eventually combined with endocrine agents, might be a reasonable option offering favorable long-term outcomes by addressing the high-risk profile associated with HER2-positive disease.

Trastuzumab in Human Epidermal Growth Factor Receptor 2-Positive Early Breast Cancer: Results of a Prospective, Noninterventional Study on Routine Treatment Between 2006 and 2012 in Germany

PURPOSE

Trastuzumab is part of the standard treatment in patients with human epidermal growth factor receptor 2-positive early breast cancer in addition to (neo)adjuvant chemotherapy. This German prospective noninterventional study, which included major patient cohorts underrepresented in the pivotal randomized studies, examined the generalizability of the results of those studies.

PATIENTS AND METHODS

Between 2006 and 2012, 4,027 patients were enrolled and treated with trastuzumab; they were unselected regarding age or concomitant/sequential adjuvant chemotherapy. Long-term outcome data were obtained in yearly intervals. All analyses were descriptive in nature.

RESULTS

Among 3,940 evaluable patients, 26% were elderly (older than 65 years of age). More than half of the population had pN0 tumor stage. Ninety-four percent received chemotherapy: 78% as adjuvant treatment and 14% as neoadjuvant treatment, 2% both. Anthracyclines were administered in 87% and taxanes in 66%. Trastuzumab was stopped prematurely in 9% (because of cardiotoxicity in 3.5%). Recurrence-free survival was 90.0% (95% confidence interval [CI], 88.9%-91.1%) and 82.8% (95% CI, 81.2%-84.4%) after 3 and 5 years, respectively. The corresponding figures for overall survival were 96.8% (95% CI, 96.1%-97.6%) and 90.0% (95% CI, 88.6%-91.4%). Pathological primary tumor size, lymph node involvement, and hormone receptor status had the greatest independent effect on recurrence risk. Cardiac function toxicity of National Cancer Institute common toxicity criteria grade ≥2 and ≥3 was observed in 2.5% and less than 1% of patients, respectively.

CONCLUSION

The maturing follow-up data seem to confirm the beneficial results of trastuzumab treatment for early breast cancer from the randomized studies. Moreover, these findings support use of trastuzumab-based therapy in patients groups less commonly included in the phase III trials (e.g., elderly patients and those with stage I disease). The Oncologist 2017;22:131-138Implications for Practice: On the basis of the results of large pivotal phase III studies, the inclusion of trastuzumab in adjuvant treatment regimens for human epidermal growth factor receptor 2-positive breast cancer is standard of care. However, in these trials, elderly patients, those with comorbidities, and/or those with contraindications or refusal of cytotoxic chemotherapy are typically underrepresented. This study provides data on observed treatment options, outcomes, and risks in a wider, unselected patient population (including more than 1,000 patients with stage I disease), treated routinely in several institutions of varying size and location across Germany.

Treosulfan in the Treatment of Advanced Ovarian Cancer - Results of a German Multicenter Non-interventional Study

BACKGROUND

Data on routine systemic treatment of patients with ovarian cancer are currently available only to a limited degree. The alkylating agent treosulfan is approved in oral (p.o.) and intravenous (i.v.) form for the treatment of ovarian carcinoma. The present non-interventional study analyzed the clinical use of treosulfan in Germany, evaluating the mode of application, toxicity, and response and survival rate.

PATIENTS AND METHODS

Two hundred and forty-eight ovarian cancer patients in 57 Centers, who received treosulfan mainly either i.v. (5,000-8,000 mg/m(2) d1, q21d or q28d) or p.o. (400-600 mg/m(2) d1-14 or 21, q28d) for at least one therapy cycle were evaluable and were included in the study.

RESULTS

With a median age of 70 years (range=36-92 years), predominantly elderly patients received treosulfan treatment. Most participants presented serous histology (131, 52.8%) and advanced-stage FIGO III (122, 49%) or IV (55, 22%) disease. Median ECOG status was 1 (range=0-2), whereas cardiac co-morbidity was common (31%). Treosulfan was usually administered as second- (26%), third- (21%) or fourth-line (17%) therapy. Two hundred and one patients received i.v. and 47 p.o.

TREATMENT

The most common reason for dose modifications was due to hematological toxicity (46%). The main reason for a therapy discontinuation was progressive disease (38.5%). Response was observed in 25.8% of participants, disease stabilization in 28.6 % and progress in 45.6%. The median progression-free and overall survival was 196 and 405 days, respectively.

CONCLUSION

In predominantly elderly and heavily pre-treated patients with recurrent ovarian cancer, treosulfan featured a clinical relevant efficacy and well-manageable, mostly hematological, toxicity, which resulted in a positive therapeutic index.

[Not Available]

Intestinal infections in Germany due to enterohemorrhagic E. coli bacteria (EHEC) between 1998 and 2001 reveal a large scale of biological diversity of their pathogens. However, no dramatic increase of their clinical importance and public health implications has been observed. As strains of serovar O157:H7 have continuously declined as causative agents, other serovars such as O26:H11 and O103:H2 have replaced them. The great diversity of the EHEC pathogens might point to a great number of various infection routes and sources. Since recently new pathogenic factors of EHEC bacteria have been detected (especially by the sequencing of the genome of EHEC), it is currently not possible to define a clear-cut difference between human pathogens and nonhuman pathogens. The enhanced surveillance of EHEC pathogens with respect to their biological diversity and dynamics, their epidemic spread, and their infection routes and sources remain an essential task of the public health authorities.

Zoonoses in the European Union: origin, distribution and dynamics - the EFSA-ECDC summary report 2009

We present a summary of the main findings of the latest report of the European Food Safety Authority and European Centre for Disease Prevention and Control on zoonoses, zoonotic agents and food-borne outbreaks in the European Union (EU), based on data from 2009. Zoonoses are prevalent and widely distributed across several countries in the EU. The most important highlight of this report was the continuous decrease of human salmonellosis since 2005, probably due to effective control programmes in livestock.

Zoonoses in the European Union: origin, distribution and dynamics - the EFSA-ECDC summary report 2009

We present a summary of the main findings of the latest report of the European Food Safety Authority and European Centre for Disease Prevention and Control on zoonoses, zoonotic agents and food-borne outbreaks in the European Union (EU), based on data from 2009. Zoonoses are prevalent and widely distributed across several countries in the EU. The most important highlight of this report was the continuous decrease of human salmonellosis since 2005, probably due to effective control programmes in livestock.

Initial surveillance of 2009 influenza A(H1N1) pandemic in the European Union and European Economic Area, April-September 2009

European Union (EU) and European Economic Area (EEA) countries reported surveillance data on 2009 pandemic influenza A(H1N1) cases to the European Centre for Disease Prevention and Control (ECDC) through the Early Warning and Response System (EWRS) during the early phase of the 2009 pandemic. We describe the main epidemiological findings and their implications in respect to the second wave of the 2009 influenza pandemic. Two reporting systems were in place (aggregate and case-based) from June to September 2009 to monitor the evolution of the pandemic. The notification rate was assessed through aggregate reports. Individual data were analysed retrospectively to describe the population affected. The reporting peak of the first wave of the 2009 pandemic influenza was reached in the first week of August. Transmission was travel-related in the early stage and community transmission within EU/EEA countries was reported from June 2009. Seventy eight per cent of affected individuals were less than 30 years old. The proportions of cases with complications and underlying conditions were 3% and 7%, respectively. The most frequent underlying medical conditions were chronic lung (37%) and cardio-vascular diseases (15%). Complication and hospitalisation were both associated with underlying conditions regardless of age. The information from the first wave of the pandemic produced a basis to determine risk groups and vaccination strategies before the start of the winter wave. Public health recommendations should be guided by early capture of profiles of affected populations through monitoring of infectious diseases.

Infection control--a European research perspective for the next decade

A symposium was held in June 2009 near Freiburg in Germany. Twenty-nine attendees from several European countries participated, most of whom are actively involved in research and hospital infection prevention and control. The following topics were presented and discussed: isolation and screening for control of multidrug-resistant organisms; impact of the environment on healthcare-associated infection (HAI); new technologies to control infection--state of evidence; surveillance of HAI; methodological challenges and research priorities for infection control and control of HAI: learning from each other in a united Europe. This Leader summarises the main issues for debate and the number of consensus points agreed amongst delegates.

Experience and lessons from surveillance and studies of the 2009 pandemic in Europe

Surveillance and studies in a pandemic is a complex topic including four distinct components: (1) early detection and investigation; (2) comprehensive early assessment; (3) monitoring; and (4) rapid investigation of the effectiveness and impact of countermeasures, including monitoring the safety of pharmaceutical countermeasures. In the 2009 pandemic, the prime early detection and investigation took place in the Americas, but Europe needed to undertake the other three components while remaining vigilant to new phenomenon such as the emergence of antiviral resistance and important viral mutation. Laboratory-based surveillance was essential and also integral to epidemiological and clinical surveillance. Early assessment was especially vital because of the many important strategic parameters of the pandemic that could not be anticipated (the 'known unknowns'). Such assessment did not need to be undertaken in every country, and was done by the earliest affected European countries, particularly those with stronger surveillance. This was more successful than requiring countries to forward primary data for central analysis. However, it sometimes proved difficult to get even those analyses from European counties, and information from Southern hemisphere countries and North America proved equally valuable. These analyses informed which public health and clinical measures were most likely to be successful, and were summarized in a European risk assessment that was updated repeatedly. The estimate of the severity of the pandemic by the World Health Organization (WHO), and more detailed description by the European Centre for Disease Prevention and Control in the risk assessment along with revised planning assumptions were essential, as most national European plans envisaged triggering more disruptive interventions in the event of a severe pandemic. Setting up new surveillance systems in the midst of the pandemic and getting information from them was generally less successful. All European countries needed to perform monitoring (Component 3) for the proper management of their own healthcare systems and other services. The information that central authorities might like to have for monitoring was legion, and some countries found it difficult to limit this to what was essential for decisions and key communications. Monitoring should have been tested for feasibility in influenza seasons, but also needed to consider what surveillance systems will change or cease to deliver during a pandemic. International monitoring (reporting upwards to WHO and European authorities) had to be kept simple as many countries found it difficult to provide routine information to international bodies as well as undertaking internal processes. Investigation of the effectiveness of countermeasures (and the safety of pharmaceutical countermeasures) (Component 4) is another process that only needs to be undertaken in some countries. Safety monitoring proved especially important because of concerns over the safety of vaccines and antivirals. It is unlikely that it will become clear whether and which public health measures have been successful during the pandemic itself. Piloting of methods of estimating influenza vaccine effectiveness (part of Component 4) in Europe was underway in 2008. It was concluded that for future pandemics, authorities should plan how they will undertake Components 2-4, resourcing them realistically and devising new ways of sharing analyses.

Incidence and risk factors for community-acquired acute gastroenteritis in north-west Germany in 2004

In developed countries, acute gastroenteritis (AGE) is a major source of morbidity. However, only a few studies have estimated its incidence and the associated medical burden. This population-based study determined the incidence of community-acquired AGE patients seeking medical care and the relative role of various pathogens. Stool samples from patients with AGE presenting to a general practitioner (GP), pediatrician, or specialist in internal medicine for that reason were screened for various bacterial and viral enteropathogens. A control group was established as well. Incidences were calculated by the number of positive patients divided by the general population. The study was performed in north-west Germany in 2004. The incidence of AGE patients requiring medical consultation was 4,020/100,000 inhabitants. Children (<5 years of age) were at the highest risk (13,810/100,000 inhabitants). Of the patients, 6.6% were tested positive for an enteropathogenic bacteria and 17.7% for a viral agent. The predominant pathogens were norovirus (626/100,000) and rotavirus (270/100,000). Salmonella was the most frequently detected bacteria (162/100,000). The results presented confirm AGE and, specifically, AGE of viral origin as a major public health burden in developed countries.

Zoonotic infections in Europe in 2007: a summary of the EFSA-ECDC annual report

The European Food Safety Authority and the European Centre for Disease Prevention and Control have just published their Community Zoonoses Report for 2007, analysing the occurrence of infectious diseases transmittable from animals to humans. Campylobacter infections still topped the list of zoonotic diseases in the European Union and the number of Salmonella infections in humans decreased for the fourth year in a row. Cases of listeriosis remained at the same level as in 2006, but due to the severity of the disease, more studies on transmission routes are warranted. The report highlights the importance of continued co-operation between veterinarians and public health specialists, both at the EU level and within Member States.

Zoonotic infections in Europe in 2007: a summary of the EFSA-ECDC annual report

The European Food Safety Authority and the European Centre for Disease Prevention and Control have just published their Community Zoonoses Report for 2007, analysing the occurrence of infectious diseases transmittable from animals to humans. Campylobacter infections still topped the list of zoonotic diseases in the European Union and the number of Salmonella infections in humans decreased for the fourth year in a row. Cases of listeriosis remained at the same level as in 2006, but due to the severity of the disease, more studies on transmission routes are warranted. The report highlights the importance of continued co-operation between veterinarians and public health specialists, both at the EU level and within Member States.

Developing the Community reporting system for foodborne outbreaks

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Developing the Community reporting system for foodborne outbreaks

Investigating and reporting of foodborne outbreaks became mandatory with Directive 2003/99/EC. In 2006 and 2007 the Community reporting system for foodborne outbreaks was further developed in an interdisciplinary approach, which is described in this paper. This involved experts on investigating and reporting foodborne outbreaks as well as experts on communicable diseases in addition to the European Food Safety Authority (EFSA) Task Force for Zoonoses Data Collection, the European Centre for Disease Prevention and Control (ECDC) Advisory Forum and representatives of ECDC, the World Health Organization (WHO), the World Organization for Animal Health (OIE) and the European Commission. European Union Member States participated in a survey regarding their national reporting systems and the needs for information on foodborne outbreaks at the Community level. The acceptability, the functionality and the data quality of the current reporting system were evaluated. The results were used to propose new variables on which data should be reported. Pick-lists were developed to facilitate reporting and better integration of the Community system with Member States' reporting systems. The new system is expected to yield better quality data on foodborne outbreaks relevant for risk assessment and risk management while reducing the work load for Member States.

The surveillance of communicable diseases in the European Union – a long-term strategy (2008-2013)

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The surveillance of communicable diseases in the European Union--a long-term strategy (2008-2013)

This article presents the steps and considerations that led to the development of the European Centre for Disease Prevention and Control s (ECDC) long-term strategy for the surveillance of communicable diseases in the European Union (EU) for the years 2008 to 2013. Furthermore, it outlines the key features of the strategy that was approved by the ECDC s Management Board in December 2007.

Molecular typing for public health purposes

By providing appropriate discriminatory analyses, molecular typing can foster rapid and – depending on the method – even real-time early detection of dispersed international clusters/outbreaks, the detection and investigation of transmission chains, the relatedness of strains, and the emergence of antimicrobial resistance and new evolving pathogenic strains.

Zoonotic infections in Europe: trends and figures - a summary of the EFSA-ECDC annual report

The 2006 annual Community Summary Report from the European Food Safety Authority (EFSA) and the European Centre for Disease Prevention and Control (ECDC) was released this week with the latest trends and figures on the occurrence of zoonotic infections and agents, antimicrobial resistance and food-borne outbreaks in the then 25 European Union Member States and five non-EU countries (Bulgaria, Iceland, Liechtenstein, Norway and Romania).

ECDC to launch first report on communicable diseases epidemiology in the European Union

The First European Communicable Disease Epidemiological Report has been launched by the European Centre for Disease Prevention and Control (ECDC) today.

Outbreak of domestically acquired typhoid fever in Leipzig, Germany, June 2004

In June 2004, three confirmed cases of typhoid fever were reported to the health authorities in Leipzig, Germany. The patients had been admitted to hospital with unexplained fever and otherwise mild symptoms. All were members of the same pony club, none had been abroad. A retrospective cohort study among pony club members was performed to identify the source of infection. A suspected case was defined as unexplained fever &gt;=38.5°C over three or more days since 1 May 2004. Additional positive serology defined a probable case and Salmonella Typhi isolation from blood or stool cultures a confirmed case. All hospitals, paediatricians and general practitioners in Leipzig and surroundings were contacted to identify additional cases. In total, six cases were identified, all among pony club members: four confirmed, including the three originally reported cases, one probable and one suspected. The only exposure common to all cases during the probable time of infection was consumption of sandwiches with herb dressing from a snack bar on 25 or 26 May (May 25: RR=5.7; 95% CI 0.9-37.9; both days: RR=, P=0.007). Foods and workers from the snack bar tested negative. However, one worker, not previously registered with the health authorities, was identified during a site visit. It cannot be excluded that further unregistered individuals worked at the snack bar between May and June 2004. Despite intense case-finding activities, no further cases were identified among the population. The most likely vehicle in this outbreak was sandwiches with herb dressing, though the source of contamination remains unknown. Even without history of travel to endemic countries, physicians should consider typhoid fever when managing patients with unexplained fever.

[Surveillance of infectious foodborne diseases after enactment of the German Protection against Infection Act in 2001. Potentials and requirements]

The epidemiology of infectious foodborne diseases has changed. Outbreaks more frequently occur geographically dispersed or protractedly over longer periods of time, and they often appear as a scatter of seemingly sporadic cases. This hampers and delays the identification of their epidemiological link. The surveillance of infectious foodborne diseases has to be refined accordingly to be able to detect these diffuse outbreaks. The German Protection against Infection Act, enacted in 2001, offers the potential of increased sensitivity due to timely electronic reporting of individual cases and detailed data accompanying each report. In addition to a timely and comprehensive reporting system, subtyping of pathogens has become an invaluable tool in identifying epidemiologically linked cases, i.e. outbreaks. Still, the sensitivity of foodborne disease surveillance still hinges on the willingness of physicians to order stool testing for enteric pathogens (and to report suspected outbreaks to local health departments). Without the active participation of physicians, the chance of detecting outbreaks and successfully investigating them is markedly reduced. Consequently, the general preventive strategy would be jeopardised, namely to understand the (often new) mechanisms by which contamination and disease transmission occur well enough to interrupt them.

Outbreak of hepatitis A in two federal states of Germany: bakery products as vehicle of infection

In April 2004, increased numbers of hepatitis A were noted in six neighbouring districts in Germany. Exploratory interviews showed that patients had consumed bakery products from company X where two employees had been diagnosed with hepatitis A in February. A case-control study of consumption of products of company X was carried out through telephone interviews. Altogether, 64 cases were identified. Fifty-two cases and 112 controls aged >or=16 years were included in the case-control study. In total, 46/52 cases and 37/112 controls had consumed company X products [odds ratio (OR) 15.5, 95% confidence interval (CI) 6.1-39.7]. Of these, 36/46 cases and 16/37 controls had consumed pastries (OR 4.7, 95% CI 1.8-12.3), 25/46 cases and 12/37 controls had consumed filled doughnuts (OR 2.5, 95% CI 1.0-6.1). Sequence analysis of the VP1-2A junction region indicated 100% strain homology between cases and an infected employee of company X. We recommended reinforcement of hygiene precautions, and consideration of a prolongation of compulsory work absence after post-exposure vaccination.

SurvNet@RKI – a multistate electronic reporting system for communicable diseases

In 2001 Germany implemented a new electronic reporting system for surveillance of notifiable infectious diseases (SurvNet@RKI). The system is currently being used in all 431 local health departments (LHD), the 16 state health departments (SHD) and the Robert Koch-Institut (RKI), the national agency for infectious disease epidemiology. The SurvNet@RKI software is written in MS Access 97 and Visual Basic and it supports MS Access as well as MS SQL Server database management systems as a back-end. The database is designed as a distributed, dynamic database for 73 reporting categories with more than 600 fields and about 7000 predefined entry values. An integrated version management system documents deletion, undeletion, completion and correction of cases at any time and entry level and allows reproduction of previously conducted queries. Integrated algorithms and help functions support data quality and the application of case definitions. RKI makes the system available to all LHDs and SHDs free of charge. RKI receives an average of 300 000 case reports and 6240 outbreak reports per year through this system. A public web-based query interface, SurvStat@RKI, assures extensive and timely publication of the data. During the 5 years that SurvNet@RKI has been running in all LHDs and SHDs in Germany it has coped well with a complex federal structure which makes this system particularly attractive to multinational surveillance networks. The system is currently being migrated to Microsoft C#/.NET and transport formats in XML. Based on our experiences, we provide recommendations for the design and implementation of national or international electronic surveillance systems.

[Risk factors for abundance of shiga toxin producing Escherichia coli in sewage water]

Shiga toxin producing Escherichia coli (STEC) in sewage influent into surface water are a potential source of human infections with STEC. Eight sewage treatment plants in Bavaria, Germany, were sampled at regular intervals from 2003 to 2004 in order to estimate STEC load and quantify risk factors. 95 of 378 samples (25 %) were tested positive for stx1and/or stx2 with PCR after enrichment culture. STEC elimination after treatment was 44 %. The following risk factors were analysed with logistic regression: location of sewage plant (rural vs. urban), treatment plant technology (two stage vs. three stage treatment) and sampling location (sewage input vs. sewage output). Rural plants had odds-ratios of 1,7 (95 % CI 1.03 - 2.69; p = 0.038) for a positive stx1 and/ or stx2 PCR result, sampling at sewage input of 2.1 (95 %CI 1.28 - 3.36; p = 0.003) and three stage plants of 1.51 (95 % CI 0.94 - 2.44; p = 0.087, not significant). Sampling after rain and after dry spells had no impact on STEC abundance (univariate Chi-square test = 0.01; df1; p = 0.920). Rural sewage plants had higher odds of STEC content. The influence of the sewage plant technology on the STEC load requires further clarification.

SurvNet@RKI--a multistate electronic reporting system for communicable diseases

In 2001 Germany implemented a new electronic reporting system for surveillance of notifiable infectious diseases (SurvNet@RKI). The system is currently being used in all 431 local health departments (LHD), the 16 state health departments (SHD) and the Robert Koch-Institut (RKI), the national agency for infectious disease epidemiology. The SurvNet@RKI software is written in MS Access 97 and Visual Basic and it supports MS Access as well as MS SQL Server database management systems as a back-end. The database is designed as a distributed, dynamic database for 73 reporting categories with more than 600 fields and about 7000 predefined entry values. An integrated version management system documents deletion, undeletion, completion and correction of cases at any time and entry level and allows reproduction of previously conducted queries. Integrated algorithms and help functions support data quality and the application of case definitions. RKI makes the system available to all LHDs and SHDs free of charge. RKI receives an average of 300,000 case reports and 6240 outbreak reports per year through this system. A public web-based query interface, SurvStat@RKI, assures extensive and timely publication of the data. During the 5 years that SurvNet@RKI has been running in all LHDs and SHDs in Germany it has coped well with a complex federal structure which makes this system particularly attractive to multinational surveillance networks. The system is currently being migrated to Microsoft C#/.NET and transport formats in XML. Based on our experiences, we provide recommendations for the design and implementation of national or international electronic surveillance systems.

Molecular epidemiology of Salmonella enterica serovar Agona: characterization of a diffuse outbreak caused by aniseed-fennel-caraway infusion

During 2002-2003 increased numbers of notified salmonellosis due to S. enterica serovar Agona were observed in Germany. In order to understand the recent spread of this serovar and to trace the route of infection to its source, a new phage-typing scheme and pulsed field gel electrophoresis (PFGE) were used to analyse these isolates. By using 14 bacteriophages, 52 phage types were distinguished among the S. Agona strains. PFGE also differentiated 52 different patterns. A combination of both methods generated 94 clonal types among 165 S. Agona strains originating from Germany and other countries including the United States, United Arab Emirates, Turkey, India, Austria and Finland, indicating a great biological diversity within this serovar. However, 36 recent S. Agona isolates from infantile gastroenteritis in Germany, from an untreated batch of aniseed imported from Turkey and from fennel-aniseed-caraway infusion (packed in tea bags) revealed clonal identity indicating their epidemiological relatedness as a new source of infection. It is suggested that strains of S. Agona will continue to be of public health concern, and that phage typing together with PFGE typing should be applied as reliable and rapid tools for epidemiological subtyping and future monitoring.

[Structure of the Surveillance and management of infectious diseases in the European Union. The EU surveillance networks and the European Centre for Disease Prevention und Control (ECDC)]

In 1998, the European Parliament and Council published the Decision on setting up a network for the epidemiological surveillance of communicable diseases in the Community. As a first step, the Network Committee (representatives of the Member States) and the Commission determined the diseases for European surveillance. Subsequently, case definitions were developed for these diseases. For rapid information exchange among Member States on serious diseases, outbreaks and the control measures taken, a web-based, password protected early warning system was established. In parallel disease-specific networks were developed for enhanced surveillance of important diseases. A training programme (EPIET) and a European bulletin (Eurosurveillance) complete the network. The directive on the monitoring of zoonoses constitutes the basis for the joint analysis and evaluation of data on human illnesses, animals and foods. Starting in May 2005, the coordination and further development of the Community Network will be carried out by the European Centre for Disease Prevention and Control (ECDC).

[The infectious disease epidemiology research network--a bridge between science and public health service. The example of the network for foodborne infections]

In order to respond to emerging food borne diseases, a new data-driven approach guided by epidemiologic and microbiologic data has been developed in Germany. An interdisciplinary network of scientists at the national, regional and local levels conducted surveillance and epidemiologic research of foodborne pathogens (Shiga toxin-producing Escherichia coli (STEC), Salmonella and Campylobacter). The objectives of the network include (1) determining incidence and distribution of STEC and Salmonella, (2) assessing the importance of typing systems for Campylobacter, (3) determining risk factors for sporadic STEC infections, (4) developing a system for detection of disperse outbreaks, including a national reference library of pulsed-field gel electrophoresis (PFGE) patterns, (5) examining risk factors for outbreaks, (6) carrying out a quantitative microbiological risk assessment for consumption of fresh chicken and (7) determining long-term sequelae of HUS patients.

[The National Reference Centres and Reference Laboratories. Importance and tasks]

Since 1995, the German Federal Ministry for Health and Social Security funds National Reference Centres (NRC) for the laboratory surveillance of important pathogens and syndromes. Which pathogens or syndromes are selected to be covered by a NRC depends on their epidemiological relevance, the special diagnostic tools, problems with antimicrobial resistance and necessary infection control measures. Currently, there are 15 NRC, which are appointed for a period of 3 years (currently from January 2005 through December 2007). Towards the end of their appointment all NRC are evaluated by a group of specialists. The assessment of their achievements is guided by a catalogue of tasks for the NRC. In addition to the NRC, a total of 50 laboratories are appointed which provide specialist expertise for additional pathogens in order to have a broad range of pathogens for which specialist laboratories are available. Their predominant task is to give advice and support for special diagnostic problems. Both NRC and the specialist laboratories are important parts of the network for infectious disease epidemiology.

Consumption, knowledge, and handling of raw meat: a representative cross-sectional survey in Germany, March 2001

Outbreaks of gastroenteritis have been repeatedly associated with the consumption of raw meat and raw meat products. To assess the potential of this problem in Germany, frequency of consumption and knowledge about and handling of raw meat during food preparation in the German population was estimated. We conducted a population-based nationwide cross-sectional survey in private households in March 2001 by random telephone numbers. Consenting German-speaking persons were randomly chosen among household members for standardized interviews. Proportions were standardized by age, sex, and region (eastern and western Germany). A total of 510 people were interviewed (response 45.1%), including 62.3% women and 31.8% considered at high risk (children younger than 10 years old, elderly more than 65 years old, and chronically ill persons). The mean age was 45.7 years. Of those who ate raw ground meat at least once a week, 17.8% lived in eastern Germany and 5.1% in western Germany, (chi-square test, P < 0.001). Teewurst was eaten by 50.8% of all respondents and 53.8% of respondents in the high-risk group. That salami or Teewurst were raw meat products was known to 58.1 and 36.3% of the respondents, respectively. Respondents reported not washing their hands (46.6%) or cleaning their cutting boards with soap (48.1%) after preparing raw meat. A total of 10.3% of the respondents had diarrhea during the last 3 months. Although knowledge is poor, consumption of raw meat products is widespread in Germany, even among high-risk persons. More information is necessary on which products contain raw meat, the potential risk of diarrhea after raw meat products are consumed, and appropriate handling of raw meat products.

An outbreak of Salmonella München in Germany associated with raw pork meat

In summer 2001, an outbreak of Salmonella München occurred in Germany. We conducted descriptive epidemiology and hypothesis-generating interviews among case patients, two retrospective cohort studies, and a case-control study of suboutbreaks. We performed pulsed-field gel electrophoresis (PFGE) from selected patient isolates and a limited trace-back investigation for analytical purposes. Four states were consecutively affected: Saxonia (SX), Brandenburg (BB), Berlin (BE), and Baden-Württemberg (BW). Although hypothesis-generating interviews failed to identify a plausible food item, descriptive data and investigations of the suboutbreaks suggested pork meat as a probable source in three states (SX, BB, and BE) but not in BW. The PFGE profiles from isolates of case patients in the first three states were indistinguishable but differed from PFGE profiles of case patients in BW. Trace-back investigation suggested that contamination of pork meat occurred early in the rearing-production chain. This outbreak demonstrates how contamination early in the production process that can yield different end products may complicate multistate outbreaks. Investigation of suboutbreaks and use of the trace-back method as investigational tools may be useful adjuncts in solving the problem of multistate outbreaks.

Outbreak of Salmonella Goldcoast infections linked to consumption of fermented sausage, Germany 2001

Salmonella Goldcoast (SGC), an uncommon serotype in Germany, was identified in 25 isolates between 1 April and 7 May 2001. To determine the cause of the outbreak, we conducted a matched case-control study including 24 cases and 51 controls. In a multivariable regression model, only consumption of a raw fermented sausage manufactured by a local company remained significant (adjusted odds ratio 20.0, 95 % confidence interval 2.7-302.5). SGC isolated from case-patients shared an indistinguishable pulsed-field gel electrophoresis pattern. A part of the produced raw fermented sausage was sold after only 4 days of fermentation. Samples from the premises and products of the company were negative for SGC. However, short-time raw fermented sausage is more likely to contain pathogens. Irradiation of raw ingredients is not accepted by German consumers, thus strict adherence to good manufacturing practices, the use of HACCP programmes as well as on-farm programmes remain crucial to reduce Salmonella.

[Zoonotic infections in humans. Review of the epidemiological situation in Germany]

Zoonosen sind Infektionskrankheiten, die auf natürlichem Weg vom Tier (Vertebraten) auf den Menschen übertragen werden können. Die Bedeutung der Zoonosen liegt in der Häufigkeit der Erkrankungsfälle, der hohen Letalität einzelner Zoonosen und der Möglichkeit von bisher auf das Tierreservoir beschränkten Erregern, die Artengrenze zum Menschen zu überwinden. Veränderte Bedingungen der Lebensmittelproduktion (inklusive Massentierhaltung) und der Ernährung sowie demographische, klimatische und ökologische Faktoren fördern die Verbreitung von Zoonoseerregern. Im Rahmen des seit 1. Januar 2001 geltenden Infektionsschutzgesetzes unterliegt eine Reihe von Zoonosen der Meldepflicht. Auf Ebene der Europäischen Union regelt u. a. die Zoonosen-Überwachungsrichtlinie, die am 17. November 2003 verabschiedet wurde, die Überwachung menschlicher Erkrankungen. Maßnahmen zur Prävention und Bekämpfung von Zoonosen müssen auf nationaler wie internationaler Ebene kontinuierlich weiterentwickelt werden.

["Emerging infectious diseases". Dengue-fever, West-Nile-fever, SARS, avian influenza, HIV]

Some emerging infectious diseases have recently become endemic in Germany. Others remain confined to specific regions in the world. Physicians notice them only when travelers after infection in endemic areas present themselves with symptoms. Several of these emerging infections will be explained. HIV is an example for an imported pathogen which has become endemic in Germany. SARS and avian influenza are zoonoses with the potential to spread from person to person. Avian influenza in humans provides a possibility for the reassortment of a potential new pandemic strain. Outbreaks of dengue fever in endemic areas are reflected in increased infections in travelers returning from these areas. Currently, West-Nile-virus infections are only imported into Germany. The timely implementation of diagnostic, therapeutic and infection control measures requires physicians to include these diseases in their differential diagnosis. To achieve this goal, good cooperation between physicians, laboratories and the public health service is essential.

The 11th international workshop on Campylobacter, Helicobacter and related Organisms (CHRO), 2001

Over 700 participants from 54 countries attended the eleventh Campylobacter, Helicobacter and Related Organisms (CHRO) meeting in September 2001. This meeting was an opportunity to update and better understand the microbiological and epidemiological complexities of Campylobacter. The mechanism of pathogenesis of this bacteria is not yet fully understood and important progress was made in the microbiological characterisation. The availability of over 100 different strain characteristics from various locations all over Europe, brought together by Campynet, is an invaluable tool for achieving this aim. There is increasing evidence to suggest that different risk factors exist for different species of Campylobacter. The link between antibiotic use in farm animals and increased resistance to some antimicrobials for humans still needs to be proved and some contradictory results reported on this issue.

SARS: retrospective cohort study among German guests of the Hotel 'M', Hong Kong

Hong Kong played a pivotal role in the international spread of the Severe Acute Respiratory Syndrome (SARS): a doctor who spent the night of 21-22 February 2003 at Hotel 'M' was identified as the index case for four national and international clusters of SARS. In parallel to the international collaborative study led by WHO and United States, a retrospective study on the cohort of German persons staying at Hotel 'M' was conducted. The inclusion criteria covered a period from 21 February to 3 March 2003 to allow the detection of cases possibly due to environmental contamination. In the twenty-one German guests traced as having stayed at Hotel "M" during this period, one case of laboratory confirmed SARS was found. The case history suggests that close vicinity to the index patient may have played a role in transmission. In line with findings of environmental investigations in the hotel, environmental contamination should be considered as a possible source of infection.

SARS-Surveillance - Wurde sie den Anforderungen an die Surveillance neu auftretender Infektionskrankheiten gerecht?

INTRODUCTION

The world-wide outbreak of severe acute respiratory syndrome (SARS) in the spring of 2003 highlighted the importance of reliable surveillance for infectious diseases. The aim of this investigation is to identify possibilities for the improvement of the German surveillance system based on the experiences made during the SARS epidemic 2003.

METHODS

The RKI has established two linked databases for the surveillance of SARS, to store case-based data on SARS and to keep a record of inquiries by the public health system. Based on these data we evaluated the information flow for the surveillance of SARS mainly qualitatively.

RESULTS AND DISCUSSION

With occurrence of the first SARS case in Germany a nationwide surveillance system for SARS was established. Since Germany was exclusively confronted with imported SARS cases, the surveillance system could fulfil the requirements. It is unclear, however, whether the current procedures are sufficient to manage larger epidemics of emerging diseases. For this task the public health system needs a uniform electronic information management system which allows rapid adaptation to the epidemic situation and is able to deal with a large amount of data.