Transmission of respiratory and gastrointestinal infections in German households with children attending child care

Transmission of acute respiratory infections (ARI) and acute gastroenteritis (AGE) often occurs in households. The aim of this study was to assess which proportion of ARI and AGE is introduced and transmitted by children in German households with children attending child care. We recruited families with children aged 0-6 years in Braunschweig (Germany), for a 4 months prospective cohort study in the winter period 2014/2015. Every household member was included in a health diary and used nasal swabs for pathogen identification in case of ARI. We defined a transmission if two persons had overlapping periods with symptoms and used additional definitions for sensitivity analyses. In total, 77 households participated with 282 persons. We observed 277 transmission events for ARI and 23 for AGE. In most cases, the first infected person in a household was a child (ARI: 63%, AGE: 53%), and the risk of within-household transmission was two times higher when the index case was a child. In 26 ARI-transmission events, pathogens were detected for both cases; hereof in 35% (95% confidence interval (17-56%)) the pathogens were different. Thus, symptomatic infections in household members, apparently linked in time, were in 2/3 associated with the same pathogens.

Foodborne hepatitis A outbreak associated with bakery products in northern Germany, 2012

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[Antimicrobial resistance monitoring in Lower Saxony (ARMIN): first trends for MRSA, ESBL-producing Escherichia coli and VRE from 2006 to 2010]

Antimicrobial resistance is one of the most important health topics of the past few years. To identify regional trends of antimicrobial resistance in inpatient and outpatient care, the Governmental Institute of Public Health of Lower Saxony (Germany) launched the sentinel system ARMIN (Antimicrobial Resistance Monitoring in Lower Saxony). Currently 9 laboratories participate as sentinel sites and contribute single case data of their microbiological results. Data are presented by an interactive data query in the internet. From 2006 to 2010 laboratories reported about 800 000 diagnostic test results. The proportion of MRSA (methicillin-resistant Staphylococcus aureus) among all Staphylococcus aureus increased from 19.5% in 2006 to 23.4% in 2010 for inpatient care in Lower Saxony. During the same period Escherichia coli resistance to cefotaxime for inpatient care increased from 3.0% to 8.8%. Enterococcus faecium resistance to vancomycin decreased from 13.6% to 5.6%. Currently the emphasis of ARMIN is on the description of trends and on the information of prescribing physicians. A quality circle was established to improve standardisation.

[H1N1 pandemic. Measures and experiences on the state level]

In order to establish a joint pandemic strategy, the German states ("Länder") together with the German federal government ("Bund") agreed on joint preparations for pandemic scenarios. This included the description of procedures, such as infection control measures, stockpiling of antiviral drugs, and contracts with vaccine manufacturers to ensure supply of vaccines in the event of a pandemic. The situation during the influenza H1N1 pandemic differed from that planned so that many short-term adjustments were required. It highlighted the need to make pandemic planning more flexible. In spite of several obstacles which had to be overcome during the situation, the states managed to achieve a relatively coordinated procedure and provided the availability of vaccines. In the course of the pandemic, gaps and shortcoming in existing surveillance systems were identified, which should lead to further improvements. A key point for future pandemic events is successful communication between all interested parties, especially with the medical profession, to increase the acceptance of public policies.

Practical usage of computer-supported outbreak detection in five European countries

This paper discusses computer-supported outbreak detection using routine surveillance data, as implemented at six institutes for infectious disease control in five European countries. We give an overview of the systems used at the Statens Serum Institut (Denmark), Health Protection Agency (England, Wales and Northern Ireland), Robert Koch Institute (Germany), Governmental Institute of Public Health of Lower Saxony (Germany), National Institute for Public Health and the Environment (the Netherlands) and Swedish Institute for Infectious Disease Control (Sweden). Despite the usefulness of the algorithms or the outbreak detection procedure itself, all institutes have experienced certain limitations of the systems. The paper therefore concludes with a list of recommendations for institutes planning to introduce computer-supported outbreak detection, based on experiences on the practical usage of the systems. This list--which concerns usability, standard operating procedures and evaluation--might also inspire improvements of systems in use today.

Practical usage of computer-supported outbreak detection in five European countries

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[Synchronising school entry health examinations in Lower-Saxony, Germany]

BACKGROUND

In the German federal state of Lower-Saxony the districts are responsible for conducting school entry health examinations. There exist two different standard protocols for diagnosis and documentation, denoted as Weser-Ems (WE) and SOPHIA. In order to analyse and improve the comparability between these two protocols, a working group was established in 2006. One of the objectives was to adjust the protocols in such a way that in the future the collected data will allow for joint health reporting.

METHODS

Each variable was discussed individually by the working group, and if diagnosis or documentation differed between the two protocols, specific modifications were proposed. For certain variables external expert opinions were obtained. For those variables that had to be revised quite generally, specific sub-working groups were established. As prerequisite for implementation, the recommendations of the working group had to be accepted by the user groups through majority votes.

RESULTS

Of 88 (WE) or, respectively, 66 (SOPHIA) variables, 39 (WE) or, respectively, 34 variables initially fulfilled the requirements for a joint analysis. As a result of the working group, for more than 20 other variables the requirements for a joint analysis could be achieved. As soon as the sub-working groups have completed their work, also the issues of physical coordination, cognitive abilities and psychological health will be available for joint analysis.

DISCUSSION

The synchronisation of school entry health examinations in Lower-Saxony is an example of how different protocols of diagnosis and documentation can be adapted to each other to enable joint data analysis without loosing their individual characteristics.

[Regionally increased incidence of notified cryptosporidiosis cases due to different laboratory methods]

INTRODUCTION

In Lower Saxony, during 2001 to 2005, 744 cases of cryptosporidiosis were reported according to the Protection against Infection Act to the Governmental Institute of Public Health of Lower Saxony. The yearly incidence rate of 1.9 notified cases per 100,000 population exceeded the German mean incidence rate of 1.5. Within Lower Saxony, there was a striking heterogeneity of regional incidences with rates greater than 10.0 in several neighbouring districts.

METHODS

A retrospective case control study was conducted in cooperation with the health departments of the 5 mostly affected districts to test the hypothesis that diagnostic effects might have caused this regional cluster. Notified cryptosporidiosis cases of the years 2002 and 2003 were analysed with respect to the notifying physicians and laboratories. Notified cases of salmonellosis and campylobacteriosis were taken as controls. Controls were matched to the cases with respect to age, sex, district, and year of notification.

RESULTS

Of the 146 cryptosporidiosis cases included in the case control study, 130 (89%) were diagnosed and reported by only one laboratory. In contrast, of the controls only 31% were reported by this laboratory. The matched odds ratio for this laboratory was 43.5 (95% confidence interval: 10.7-177; p<0.001).

DISCUSSION

The case control study revealed a significant association of the cryptosporidiosis notifications with one particular laboratory. Confounding by co-variables like age or district could be excluded due to matching. In this laboratory all stool samples submitted for routine microbiological diagnosis were screened for Cryptosporidium parvum. Diagnostic work was done by valid, specific, CE-certified procedures. We conclude that the increased regional incidence rate caused by the broader diagnostic activity of this laboratory rather reflects the real occurrence of this infection. Hence, in other regions with lower incidence rates of notified cases an underestimation can be presumed.

[Surveillance of acute respiratory illnesses (ARI) in Lower Saxony: first experience from the years 2005-2006]

In the context of influenza pandemic preparedness planning, a surveillance system for influenza and other acute respiratory illnesses was implemented in Lower Saxony at the beginning of the influenza season 2004/2005 and coordinated by the Governmental Institute of Public Health of Lower Saxony. This surveillance system represents an addition to already existing national monitoring systems. The goal of this surveillance system is to have available prompt information on the beginning, course and end of the influenza season and to recognise the spectrum of pathogens and identify outbreaks of other viral acute respiratory illnesses (ARI). For this purpose an all-season surveillance was established consisting of two supplementary modules. The first module is a symptom-oriented surveillance of acute respiratory illnesses in children of pre-school day care facilities. In the second module a virological surveillance in co-operation with selected medical practices was established. While the temporal course and burden of ARI in all Lower Saxony can be assessed by the surveillance of children in the day-care facilities in a sensitive, but less specific way, the virological surveillance provides highly specific information on the prevailing pathogens in ARI patients at a certain time. This information, in return, gives an indication about the responsible pathogens causing ARI in children of the day-care facilities. The first experience with these two complementary surveillance modules shows that in Lower Saxony a well accepted, prompt and meaningful monitoring system is available for the recognition and description of the occurrence of ARI and concomitantly of influenza. An extension of this surveillance to other pathogens or disease scenarios is possible.

Legionnaires' disease outbreak associated with a cruise liner, August 2003: epidemiological and microbiological findings

Eight cases of Legionnaires' disease were identified among the 215 German passengers after a cruise to the Nordic Sea in August 2003. An unmatched case-control study was conducted to identify risk factors and the source of infection. In total, eight passengers fulfilled the case definition, one of these died. Forty-two passengers served as controls. The attack rate was 4%. The mean age was 60 years for cases and 62 years for controls. Prolonged exposure to the spa pool seemed to be a risk factor of infection (OR 4.85, P=0.09). Legionella pneumophila serogroup 1, monoclonal antibody (mAb) subgroup 'Knoxville' was isolated from clinical and environmental samples. DNA sequence-based typing revealed that these isolates were indistinguishable from each other. The investigation showed the importance of an interdisciplinary approach of microbiology and epidemiology as not all sites on the ship that tested positive for L. pneumophila actually posed a relevant risk for the passengers.

[Spatial-statistical analysis of infectious disease notification data in lower saxony]

BACKGROUND

In Lower Saxony the analysis of notification data according to the infection protection law is based on two pillars: one pillar is the weekly analysis to identify clusters and locally non-detectable outbreaks by an early warning system. The second pillar is an annual reporting system for obtaining an overall picture and for identifying long-term trends. In both fields methods of spatial statistics are applied.

METHODS

For the 16 most frequent notifiable diseases, the notification data of the districts of Lower Saxony are analysed and presented on the Internet. The presentation starts with an overview page, on which differences between observed and expected case counts for these diseases are presented tabulated and graphically. On a separate page for each disease the temporal and spatial distribution is shown by means of the following graphs: Time series presentation (weekly case counts and moving averages), chloropleth map of regional incidence rates and dot map of regional case counts. For identification of outbreaks, Kulldorff's "scan statistic" is used to search the data for clusters and to assess the significance of these clusters. The methods are executed mainly automatically using predominantly public domain software.

RESULTS AND DISCUSSION

The approach attempts to meet the surveillance principle of providing the participants with immediate feedback. The scan statistics is a universal objective instrument for detecting and assessing spatial clusters. A special advantage is the identification of clusters which include several districts. The properties of the identified clusters (spatial extension, number of cases) offer some insight into the characteristic epidemiology of the diseases.

[Investigation of a listeriosis cluster: how complete are laboratory-based reports?]

BACKGROUND

In Germany, listeriosis surveillance is based on mandatory laboratory notification of Listeria monocytogenes. Local public health departments (LPHDs) forward the received reports anonymously to state public health departments (SPHDs) which send them to the national public health centre. For the 28th reporting week (RW) 2003, LPHDs reported four cases of listeriosis to the SPHD of Hesse, cumulating to 19 listeriosis cases in 2003 compared to four cases in RW 1 - 28, 2002.

METHODS

To investigate this cluster, we asked LPHDs in Hesse and Lower Saxony, where a comparable increase in cases was observed, to collect food histories for the four weeks preceding illness for cases reported from 25. - 29. RW 2003. We performed laboratory-based active case detection by contacting laboratories accepting clinical specimens from Hesse, and evaluated reporting completeness at the state level for the period 1.1.2002 - 31.8.2003.

RESULTS

Food histories of the eight cases interviewed did not permit to incriminate any particular food item. Of the 49 listeriosis cases identified through either LPHDs or active case detection, 29 (59 %) were reported, forwarded to the SPHD and identified through active case detection and four (8 %) were reported and forwarded, but not identified through active case detection. Four cases (8 %) were reported to three LPHDs, but not forwarded to the SPHD. These were identified through active case detection. Further twelve cases (24 %) were exclusively identified through active case detection.

CONCLUSIONS

This assessment of reporting completeness suggests that the number of laboratory confirmed listeriosis cases exceeds the number registered at state level by at least 48 %. Completeness might be improved by electronic, automated reporting.

[Infectious disease surveillance based on the Protection against Infection Act in the German public health sector]

By the Protection against Infection Act new instruments were established for infectious disease surveillance in Germany. The main innovations were a shift of responsibility for notifications from clinicians to laboratories, the validation of cases by means of case definitions in local public health departments, and the electronic transmission of single case data via state health departments to the Robert Koch Institute. Four years after the Protection against Infection Act was enacted, its implementation was successful from the perspective of state and national health authorities. This was proven by the detection and successful investigation of several diffuse outbreaks. However, further improvements seem necessary and the following points should be considered in a revision of the act: reduction of time limits for data transmission, unambiguous regulation of responsibilities and for data exchange in non-localized outbreaks as well as for international exchange of case data, and introduction of an obligation for clinicians to supply local public health departments with complementary information regarding laboratory reports on demand. The public health sector can contribute to a further improvement of the surveillance system by working to better inform clinicians and laboratories and therewith motivate them to comply with their obligations for notifying diseases and by promoting the scientific evaluation of the system, in particular concerning potential underreporting.

[The epidemiology of human enterohemorrhagic Escherichia coli infections in Lower Saxony]

BACKGROUND

In the German federal state Lower Saxony, data on infections with enterohemorrhagic Escherichia coli (EHEC) and hemolytic uremic syndrome (HUS) are collected systematically since 1997 based on reports by physicians and laboratories. Initially the data were collected by means of a specific established surveillance system, since 2001 they are collected as part of the new infectious disease law.

RESULTS

From 1997 to 2003, in Lower Saxony 880 EHEC-infections and 112 HUS-cases, 6 of whom died, were notified. This corresponds to an incidence of 1.6 EHEC-infections and 0.2 HUS-cases per 100000 person-years. No secular trend was observ-ed for the yearly number of HUS-cases, but raised numbers were observed for the years 1997 and 2002. There were strong regional differences of the EHEC/HUS-incidence from 0.7 in the district Braunschweig to 3.5 in the district Weser-Ems. For 56% of reported EHEC-cases, serotype information was available. The most frequent serogroup was O157, accounting for 30% of cases with serotype information. Of HUS-cases with known serotype, 86% were caused by O157, 20% by O157:H-. 52% of the EHEC-cases were less than 5 years old (HUS: 77%), and 68% less than 10 years (HUS: 92%). 23% of EHEC/HUS-cases could be identified as part of clusters with a mean number of 2.6 cases per cluster. These clusters almost exclusively affect-ed families. Though the data also contained information on possible sources or routes of infection, for none of the cases a microbiologically assured source was documented.

CONCLUSIONS

The incidences of EHEC and HUS were higher in Lower-Saxony than in the whole of Germany. During the study period no significant trends concerning the number of HUS-cases or the distribution of serotypes were observed. More frequent serotyping and more complete information on sources or risks of infection should be achieved.