An appeal for strengthening genomic pathogen surveillance to improve pandemic preparedness and infection prevention: the German perspective.

The SARS-CoV-2 pandemic has highlighted the importance of viable infection surveillance and the relevant infrastructure. From a German perspective, an integral part of this infrastructure, genomic pathogen sequencing, was at best fragmentary and stretched to its limits due to the lack or inefficient use of equipment, human resources, data management and coordination. The experience in other countries has shown that the rate of sequenced positive samples and linkage of genomic and epidemiological data (person, place, time) represent important factors for a successful application of genomic pathogen surveillance. Planning, establishing and consistently supporting adequate structures for genomic pathogen surveillance will be crucial to identify and combat future pandemics as well as other challenges in infectious diseases such as multi-drug resistant bacteria and healthcare-associated infections. Therefore, the authors propose a multifaceted and coordinated process for the definition of procedural, legal and technical standards for comprehensive genomic pathogen surveillance in Germany, covering the areas of genomic sequencing, data collection and data linkage, as well as target pathogens. A comparative analysis of the structures established in Germany and in other countries is applied. This proposal aims to better tackle epi- and pandemics to come and take action from the "lessons learned" from the SARS-CoV-2 pandemic.

Quality of life and mental health in children and adolescents during the first year of the COVID-19 pandemic: results of a two-wave nationwide population-based study.

BACKGROUND: The COVID-19 pandemic has disrupted the lives of children and adolescents worldwide. The German COPSY study is among the first population-based longitudinal studies to examine the mental health impact of the pandemic. The objective of the study was to assess changes in health-related quality of life (HRQoL) and mental health in children and adolescents and to identify the associated risk and resource factors during the pandemic. METHODS: A nationwide longitudinal survey was conducted with two waves during the pandemic (May/June 2020 and December 2020/January 2021). In total, n = 1923 children and adolescents aged 7 to 17 years and their parents participated (retention rate from wave 1 to wave 2: 85%). The self-report and parent-proxy surveys assessed HRQoL (KIDSCREEN-10), mental health problems (SDQ with the subscales emotional problems, conduct problems, hyperactivity, and peer problems), anxiety (SCARED), depressive symptoms (CES-DC, PHQ-2) and psychosomatic complaints (HBSC-SCL). Mixed model panel regression analyses were conducted to examine longitudinal changes in mental health and to identify risk and resource factors. RESULTS: The HRQoL of children and adolescents decreased during the pandemic, and emotional problems, peer-related mental health problems, anxiety, depressive and psychosomatic symptoms increased over time, however the change in global mental health problems from wave 1 to wave 2 was not significant, and some changes were negligible. Socially disadvantaged children and children of mentally burdened parents were at particular risk of impaired mental health, while female gender and older age were associated with fewer mental health problems. A positive family climate and social support supported the mental health of children and adolescents during the pandemic. DISCUSSION: Health promotion, prevention and intervention strategies could support children and adolescents in coping with the pandemic and protect and maintain their mental health.

Monitoring the SARS-CoV-2 Pandemic: Prevalence of Antibodies in a Large, Repetitive Cross-Sectional Study of Blood Donors in Germany-Results from the SeBluCo Study 2020-2022.

SARS-CoV-2 serosurveillance is important to adapt infection control measures and estimate the degree of underreporting. Blood donor samples can be used as a proxy for the healthy adult population. In a repeated cross-sectional study from April 2020 to April 2021, September 2021, and April/May 2022, 13 blood establishments collected 134,510 anonymised specimens from blood donors in 28 study regions across Germany. These were tested for antibodies against the SARS-CoV-2 spike protein and nucleocapsid, including neutralising capacity. Seroprevalence was adjusted for test performance and sampling and weighted for demographic differences between the sample and the general population. Seroprevalence estimates were compared to notified COVID-19 cases. The overall adjusted SARS-CoV-2 seroprevalence remained below 2% until December 2020 and increased to 18.1% in April 2021, 89.4% in September 2021, and to 100% in April/May 2022. Neutralising capacity was found in 74% of all positive specimens until April 2021 and in 98% in April/May 2022. Our serosurveillance allowed for repeated estimations of underreporting from the early stage of the pandemic onwards. Underreporting ranged between factors 5.1 and 1.1 in the first two waves of the pandemic and remained well below 2 afterwards, indicating an adequate test strategy and notification system in Germany.

SARS-CoV-2 infections in migrant populations in Germany: results from the COVID-19 snapshot monitoring survey.

OBJECTIVES: Research shows that there is an increased risk of SARS-CoV-2 infection in migrants and ethnic minorities. However, increasing evidence indicates that socio-economic factors, such as employment, education and income, contribute to the association between migrant status and SARS-CoV-2 infection. This study aimed to examine the association between migrant status and the risk of SARS-CoV-2 infection in Germany and to discuss potential explanations for these associations. STUDY DESIGN: This was a cross-sectional study. METHODS: Data from the German COVID-19 Snapshot Monitoring online survey were analysed, and hierarchical multiple linear regression models were used to calculate the probabilities of self-reported SARS-CoV-2 infection. Predictor variables were integrated in a stepwise method as follows: (1) migrant status (defined by own or parental country of birth other than Germany); (2) gender, age and education; (3) household size; (4) household language; and (5) occupation in the health sector, including an interaction term of migrant status (yes) and occupation in the health sector (yes). RESULTS: Of 45,858 participants, 3.5% reported a SARS-CoV-2 infection, and 16% were migrants. Migrants, participants in large households, those speaking a language other than German in their household and those working in the health sector were more likely to report SARS-CoV-2 infection. The probability of reporting SARS-CoV-2 infection was 3.95 percentage points higher for migrants than non-migrants; this probability decreased when integrating further predictor variables. The strongest association of reporting a SARS-CoV-2 infection was observed for migrants working in the health sector. CONCLUSIONS: Migrants and health sector employees, and especially migrant health workers, are at an increased risk of SARS-CoV-2 infection. The results show that the risk of SARS-CoV-2 infection is determined by living and working conditions rather than migrant status.

SARS-CoV-2 infections in migrant populations in Germany: results from the COVID-19 Snapshot Monitoring Survey

Objectives Research shows that there is an increased risk of SARS-CoV-2 infection in migrants and ethnic minorities. However, increasing evidence indicates that socio-economic factors, such as employment, education and income, contribute to the association between migrant status and SARS-CoV-2 infection. This study aimed to examine the association between migrant status and the risk of SARS-CoV-2 infection in Germany, and to discuss potential explanations for these associations. Study design Cross-sectional study. Methods Data from the German COVID-19 Snapshot Monitoring online survey were analysed and hierarchical multiple linear regression models were used to calculate the probabilities of self-reported SARS-CoV-2 infection. Predictor variables were integrated in a stepwise method as follows: (1) migrant status (defined by own or parental country of birth other than Germany);(2) gender, age and education;(3) household size;(4) household language;and (5) occupation in the health sector, including an interaction term of migrant status (yes) and occupation in the health sector (yes). Results Of 45,858 participants, 3.5% reported a SARS-CoV-2 infection and 16% were migrants. Migrants, participants in large households, those speaking a language other than German in their household and those working in the health sector were more likely to report SARS-CoV-2 infection. The probability of reporting SARS-CoV-2 infection was 3.95 percentage points higher for migrants than non-migrants;this probability decreased when integrating further predictor variables. The strongest association of SARS-CoV-2 infection was observed for migrants working in the health sector. Conclusions Migrants and health sector employees, especially migrant health workers, are at an increased risk of SARS-CoV-2 infection. Results show that the risk of SARS-CoV-2 infection is determined by living and working conditions rather than migrant status.

[Establishment of genomic pathogen surveillance to strengthen pandemic preparedness and infection prevention in Germany]. / Etablierung der Genomischen Erreger-Surveillance zur Stärkung des Pandemie- und Infektionsschutzes in Deutschland.

The SARS-CoV­2 pandemic has shown a deficit of essential epidemiological infrastructure, especially with regard to genomic pathogen surveillance in Germany. In order to prepare for future pandemics, the authors consider it urgently necessary to remedy this existing deficit by establishing an efficient infrastructure for genomic pathogen surveillance. Such a network can build on structures, processes, and interactions that have already been initiated regionally and further optimize them. It will be able to respond to current and future challenges with a high degree of adaptability.The aim of this paper is to address the urgency and to outline proposed measures for establishing an efficient, adaptable, and responsive genomic pathogen surveillance network, taking into account external framework conditions and internal standards. The proposed measures are based on global and country-specific best practices and strategy papers. Specific next steps to achieve an integrated genomic pathogen surveillance include linking epidemiological data with pathogen genomic data; sharing and coordinating existing resources; making surveillance data available to relevant decision-makers, the public health service, and the scientific community; and engaging all stakeholders. The establishment of a genomic pathogen surveillance network is essential for the continuous, stable, active surveillance of the infection situation in Germany, both during pandemic phases and beyond.

Estimating the share of SARS-CoV-2-immunologically naïve individuals in Germany up to June 2022.

After the winter of 2021/2022, the coronavirus disease 2019 (COVID-19) pandemic had reached a phase where a considerable number of people in Germany have been either infected with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant, vaccinated or both, the full extent of which was difficult to estimate, however, because infection counts suffer from under-reporting, and the overlap between the vaccinated and recovered subpopulations is unknown. Yet, reliable estimates regarding population-wide susceptibility were of considerable interest: Since both previous infection and vaccination reduce the risk of severe disease, a low share of immunologically naïve individuals lowers the probability of further severe outbreaks, given that emerging variants do not escape the acquired susceptibility reduction. Here, we estimate the share of immunologically naïve individuals by age group for each of the sixteen German federal states by integrating an infectious-disease model based on weekly incidences of SARS-CoV-2 infections in the national surveillance system and vaccine uptake, as well as assumptions regarding under-ascertainment. We estimate a median share of 5.6% of individuals in the German population have neither been in contact with vaccine nor any variant up to 31 May 2022 (quartile range [2.5%-8.5%]). For the adult population at higher risk of severe disease, this figure is reduced to 3.8% [1.6%-5.9%] for ages 18-59 and 2.1% [1.0%-3.4%] for ages 60 and above. However, estimates vary between German states mostly due to heterogeneous vaccine uptake. Excluding Omicron infections from the analysis, 16.3% [14.1%-17.9%] of the population in Germany, across all ages, are estimated to be immunologically naïve, highlighting the large impact the first two Omicron waves had until the beginning of summer in 2022. The method developed here might be useful for similar estimations in other countries or future outbreaks of other infectious diseases.

[Attitudes Toward Influenza Vaccination in Fall/Winter 2021: Results of the COSMO Study]. / Einstellung zur Grippeimpfung im Herbst/Winter 2021: Ergebnisse der COSMO-Studie.

AIM OF THE STUDY: There is a lack of knowledge about attitudes to influenza vaccination in Germany in 2021/2022. Based on the COSMO survey ("COVID-19 Snapshot Monitoring"), the aim of this study was to shed some light on this topic. METHODS: Wave 49 (August 10 and 11, 2021) of the COSMO survey (n=967; Germany-wide non-probabilistic quota sample; 18 to 74 years). RESULTS: This year, about one-third of respondents (and health care workers) plan to get a flu shot, and among the at-risk group of people aged 60 and older (up to 74 years in our sample), more than half. Correlates (such as gender: women with a lower likelihood of a planned flu shot) were identified. CONCLUSION: Physicians should inform women in particular about the advantages of influenza vaccination, especially during the pandemic, and communicate data on the proven protective effect of influenza vaccination as convincingly as possible (e. g., using existing brochures).

Nationally representative results on SARS-CoV-2 seroprevalence and testing in Germany at the end of 2020.

Pre-vaccine SARS-CoV-2 seroprevalence data from Germany are scarce outside hotspots, and socioeconomic disparities remained largely unexplored. The nationwide representative RKI-SOEP study (15,122 participants, 18-99 years, 54% women) investigated seroprevalence and testing in a supplementary wave of the Socio-Economic-Panel conducted predominantly in October-November 2020. Self-collected oral-nasal swabs were PCR-positive in 0.4% and Euroimmun anti-SARS-CoV-2-S1-IgG ELISA from dry-capillary-blood antibody-positive in 1.3% (95% CI 0.9-1.7%, population-weighted, corrected for sensitivity = 0.811, specificity = 0.997). Seroprevalence was 1.7% (95% CI 1.2-2.3%) when additionally correcting for antibody decay. Overall infection prevalence including self-reports was 2.1%. We estimate 45% (95% CI 21-60%) undetected cases and lower detection in socioeconomically deprived districts. Prior SARS-CoV-2 testing was reported by 18% from the lower educational group vs. 25% and 26% from the medium and high educational group (p < 0.001, global test over three categories). Symptom-triggered test frequency was similar across educational groups. Routine testing was more common in low-educated adults, whereas travel-related testing and testing after contact with infected persons was more common in highly educated groups. This countrywide very low pre-vaccine seroprevalence in Germany at the end of 2020 can serve to evaluate the containment strategy. Our findings on social disparities indicate improvement potential in pandemic planning for people in socially disadvantaged circumstances.

Corona Monitoring Nationwide (RKI-SOEP-2): Seroepidemiological Study on the Spread of SARS-CoV-2 Across Germany

SARS-CoV-2, the coronavirus, spread across Germany within just a short period of time. Seroepidemiological studies are able to estimate the proportion of the population with antibodies against SARS-CoV-2 infection (seroprevalence) as well as the level of undetected infections, which are not captured in official figures. In the seroepidemiological study Corona Monitoring Nationwide (RKI-SOEP-2), biospecimens and interview data were collected in a nationwide population-based subsample of the Socio-Economic Panel (SOEP). By using laboratory-analyzed blood samples to detect antibodies to the SARS-CoV-2 virus, we were able to identify a history of vaccination or infection in study participants. By combining these results with survey data, we were able to identify groups within the population that are at increased risk of infection. By linking the RKI-SOEP-2 survey data with data from other waves of the SOEP survey, we will be able to examine the medium- to long-term impacts of the COVID-19 pandemic, including effects of long COVID, in diverse areas of life. Furthermore, the data provide insight into the population's willingness to be vaccinated as well as related attitudes and conditions. In sum, the RKI-SOEP-2 survey data offer a better understanding of the scope of the epidemic in Germany and can help in identifying target groups for infection control in the present and future pandemics.

Child and Adolescent Mental Health During the COVID-19 Pandemic: Results of the Three-Wave Longitudinal COPSY Study.

PURPOSE: The German population-based longitudinal COVID-19 andPsychological Health study monitors changes in health-related quality of life (HRQoL) and mental health of children and adolescents during the COVID-19 pandemic and identifies vulnerable groups. METHODS: A nationwide, population-based survey was conducted in May 2020 to June 2020 (Wave 1), December 2020 to January 2021 (Wave 2), and September 2021 to October 2021 (Wave 3). In total, n = 2,097 children and adolescents aged 7-17 years were investigated using measures to assess HRQoL (KIDSCREEN-10), mental health problems (SDQ), anxiety (SCARED), depressive symptoms(PHQ-2), and psychosomatic complaints(HBSC-SCL). RESULTS: The prevalence of low HRQoL increased from 15% prepandemic to 40% and 48% in Waves 1 and 2 and improved slightly to 35% in Wave 3 (all differences significant). Similarly, overall mental health problems increased from 18% prepandemic to 29% in Wave 1 and 31% in Wave 2 to 28% in Wave 3 (all differences significant, except Wave 3 vs. 2), anxiety increased from 15% prepandemic to 24% and 30% in Waves 1 and 2 and was still 27% in Wave 3. Depressive symptoms increased from 10% prepandemic to 11% and 15% in Waves 1 and 2 and were 11% in Wave 3. A group with low parental education, restricted living conditions, migration background, and parental mental health problems was at significantly increased risk of HRQoL and mental health impairments. DISCUSSION: The prevalence of low HRQoL, mental health problems, and anxiety has been elevated throughout the pandemic. Thus, mental health promotion, prevention, and intervention strategies need to be implemented to support adolescents-particularly those at risk.

Transmission of SARS-CoV-2 among children and staff in German daycare centres.

In daycare centres, the close contact of children with other children and employees favours the transmission of infections. The majority of children <6 years attend daycare programmes in Germany, but the role of daycare centres in the SARS-CoV-2 pandemic is unclear. We investigated the transmission risk in daycare centres and the spread of SARS-CoV-2 to associated households. 30 daycare groups with at least one recent laboratory-confirmed SARS-CoV-2 case were enrolled in the study (10/2020-06/2021). Close contact persons within daycare and households were examined over a 12-day period (repeated SARS-CoV-2 PCR tests, genetic sequencing of viruses, symptom diary). Households were interviewed to gain comprehensive information on each outbreak. We determined primary cases for all daycare groups. The number of secondary cases varied considerably between daycare groups. The pooled secondary attack rate (SAR) across all 30 daycare centres was 9.6%. The SAR tended to be higher when the Alpha variant was detected (15.9% vs. 5.1% with evidence of wild type). The household SAR was 53.3%. Exposed daycare children were less likely to get infected with SARS-CoV-2 than employees (7.7% vs. 15.5%). Containment measures in daycare programmes are critical to reduce SARS-CoV-2 transmission, especially to avoid spread to associated households.

Seroepidemiological study on the spread of SARS-CoV-2 in Germany: Study protocol of the CORONA-MONITORING bundesweit' study (RKI-SOEP study).

The SARS-CoV-2 coronavirus has spread rapidly across Germany. Infections are likely to be under-recorded in the notification data from local health authorities on laboratory-confirmed cases since SARS-CoV-2 infections can proceed with few symptoms and then often remain undetected. Seroepidemiological studies allow the estimation of the proportion in the population that has been infected with SARS-CoV-2 (seroprevalence) as well as the extent of undetected infections. The 'CORONA-MONITORING bundesweit' study (RKI-SOEP study) collects biospecimens and interview data in a nationwide population sample drawn from the German Socio-Economic Panel (SOEP). Participants are sent materials to self-collect a dry blood sample of capillary blood from their finger and a swab sample from their mouth and nose, as well as a questionnaire. The samples returned are tested for SARS-CoV-2 IgG antibodies and SARS-CoV-2 RNA to identify past or present infections. The methods applied enable the identification of SARS-CoV-2 infections, including those that previously went undetected. In addition, by linking the data collected with available SOEP data, the study has the potential to investigate social and health-related differences in infection status. Thus, the study contributes to an improved understanding of the extent of the epidemic in Germany, as well as identification of target groups for infection protection.

Seroepidemiological study on the spread of SARS-CoV-2 in populations in especially affected areas in Germany - Study protocol of the CORONA-MONITORING lokal study.

At a regional and local level, the COVID-19 pandemic has not spread out uniformly and some German municipalities have been particularly affected. The seroepidemiological data from these areas helps estimate the proportion of the population that has been infected with SARS-CoV-2 (seroprevalence), as well as the number of undetected infections and asymptomatic cases. In four municipalities which were especially affected, 2,000 participants will be tested for an active SARS-CoV-2 infection (oropharyngeal swab) or a past infection (blood specimen IgG antibody test). Participants will also be asked to fill out a short written questionnaire at study centres and complete a follow-up questionnaire either online or by telephone, including information on issues such as possible exposure, susceptability, symptoms and medical history. The CORONA-MONITORING lokal study will allow to determine the proportion of the population with SARS-CoV-2 antibodies in four particularly affected locations. This study will increase the accuracy of estimates regarding the scope of the epidemic, help determine risk and protective factors for an infection and therefore also identify especially exposed groups and, as such, it will be crucial towards planning of prevention measures.

SARS-CoV-2 Transmissibility Within Day Care Centers-Study Protocol of a Prospective Analysis of Outbreaks in Germany.

Introduction: Until today, the role of children in the transmission dynamics of SARS-CoV-2 and the development of the COVID-19 pandemic seems to be dynamic and is not finally resolved. The primary aim of this study is to investigate the transmission dynamics of SARS-CoV-2 in child day care centers and connected households as well as transmission-related indicators and clinical symptoms among children and adults. Methods and Analysis: COALA ("Corona outbreak-related examinations in day care centers") is a day care center- and household-based study with a case-ascertained study design. Based on day care centers with at least one reported case of SARS-CoV-2, we include one- to six-year-old children and staff of the affected group in the day care center as well as their respective households. We visit each child's and adult's household. During the home visit we take from each household member a combined mouth and nose swab as well as a saliva sample for analysis of SARS-CoV-2-RNA by real-time reverse transcription polymerase chain reaction (real-time RT-PCR) and a capillary blood sample for a retrospective assessment of an earlier SARS-CoV-2 infection. Furthermore, information on health status, socio-demographics and COVID-19 protective measures are collected via a short telephone interview in the subsequent days. In the following 12 days, household members (or parents for their children) self-collect the same respiratory samples as described above every 3 days and a stool sample for children once. COVID-19 symptoms are documented daily in a symptom diary. Approximately 35 days after testing the index case, every participant who tested positive for SARS-CoV-2 during the study is re-visited at home for another capillary blood sample and a standardized interview. The analysis includes secondary attack rates, by age of primary case, both in the day care center and in households, as well as viral shedding dynamics, including the beginning of shedding relative to symptom onset and viral clearance. Discussion: The results contribute to a better understanding of the epidemiological and virological transmission-related indicators of SARS-CoV-2 among young children, as compared to adults and the interplay between day care and households.

The four weeks before lockdown during the COVID-19 pandemic in Germany: a weekly serial cross-sectional survey on risk perceptions, knowledge, public trust and behaviour, 3 to 25 March 2020.

BackgroundDuring the COVID-19 pandemic, public perceptions and behaviours have had to adapt rapidly to new risk scenarios and radical behavioural restrictions.AimTo identify major drivers of acceptance of protective behaviours during the 4-week transition from virtually no COVID-19 cases to the nationwide lockdown in Germany (3-25 March 2020).MethodsA serial cross-sectional online survey was administered weekly to ca 1,000 unique individuals for four data collection rounds in March 2020 using non-probability quota samples, representative of the German adult population between 18 and 74 years in terms of age × sex and federal state (n = 3,910). Acceptance of restrictions was regressed on sociodemographic variables, time and psychological variables, e.g. trust, risk perceptions, self-efficacy. Extraction of homogenous clusters was based on knowledge and behaviour.ResultsAcceptance of restrictive policies increased with participants' age and employment in the healthcare sector; cognitive and particularly affective risk perceptions were further significant predictors. Acceptance increased over time, as trust in institutions became more relevant and trust in media became less relevant. The cluster analysis further indicated that having a higher education increased the gap between knowledge and behaviour. Trust in institutions was related to conversion of knowledge into action.ConclusionIdentifying relevant principles that increase acceptance will remain crucial to the development of strategies that help adjust behaviour to control the pandemic, possibly for years to come. Based on our findings, we provide operational recommendations for health authorities regarding data collection, health communication and outreach.

Sociodemographic characteristics determine download and use of a Corona contact tracing app in Germany-Results of the COSMO surveys.

During the SARS-CoV-2 pandemic mobile health applications indicating risks emerging from close contacts to infected persons have a large potential to interrupt transmission chains by automating contact tracing. Since its dispatch in Germany in June 2020 the Corona Warn App has been downloaded on 25.7 Mio smartphones by February 2021. To understand barriers to download and user fidelity in different sociodemographic groups we analysed data from five consecutive cross-sectional waves of the COVID-19 Snapshot Monitoring survey from June to August 2020. Questions on the Corona Warn App included information on download, use, functionality, usability, and consequences of the app. Of the 4,960 participants (mean age 45.9 years, standard deviation 16.0, 50.4% female), 36.5% had downloaded the Corona Warn App. Adjusted analysis found that those who had downloaded the app were less likely to be female (Adjusted Odds Ratio for men 1.16 95% Confidence Interval [1.02;1.33]), less likely to be younger (Adjusted Odds Ratio for age 18 to 39 0.47 [0.32;0.59] Adjusted Odds Ratio for age 40 to 64 0.57 [0.46;0.69]), less likely to have a lower household income (AOR 0.55 [0.43;0.69]), and more likely to live in one of the Western federal states including Berlin (AOR 2.31 [1.90;2.82]). Willingness to disclose a positive test result and trust in data protection compliance of the Corona Warn App was significantly higher in older adults. Willingness to disclose also increased with higher educational degrees and income. This study supports the hypothesis of a digital divide that separates users and non-users of the Corona Warn App along a well-known health gap of education, income, and region.