Implications of a change in case definition and screening of asylum seekers for hepatitis B surveillance in Germany in 2015 and 2016.

Since 2015, the number of hepatitis B virus (HBV) cases increased substantially in Germany. In 2015, a more sensitive HBV case definition was introduced. This coincided with an asylum seeker influx with differing screening strategies. Information on the asylum seeker status has been collected since 09/2015. We investigated this increase to interpret HBV notification data in Germany. We compared HBV surveillance data from 2010-2013 (baseline) with 2015-2016, excluding 2014 due to beginning of asylum seeker influx. We estimated the excess above the mean case number (baseline) using Poisson regression and compared asylum seeker cases and the excess of cases with the unknown asylum seeker status. HBV cases increased from 1855 (mean baseline) to 3873 (2015) and 3466 (2016) with 1903 asylum seeker cases and 1099 excess-cases with the unknown asylum seeker status in 2015-2016. Cases only fulfilling the changed case definition increased from 60% (1119) in baseline to 81% (P < 0.01) in 2015-2016; 69% of asylum seeker cases and 61% of excess-cases were males <40 years compared to 27% (baseline) (P < 0.01). Changed case definition increased the number of cases in official statistics substantially. Demographic and geographical distributions suggest that screening of asylum seekers increased the case numbers even to a higher extent than surveillance data indicates.

Evaluation of the German surveillance system for hepatitis B regarding timeliness, data quality, and simplicity, from 2005 to 2014.

OBJECTIVES: Germany has a mandatory surveillance system for acute hepatitis B (AHB) with the Protection against Infection Act as the legal basis in place since 2001. An amendment was introduced in 2013. We aimed at evaluating the surveillance systems' performance regarding timeliness, data quality, and simplicity from 2005 to 2014 and at assessing the effect of the amendment on timeliness of AHB surveillance. STUDY DESIGN: This study is a trend analysis of surveillance data. METHODS: Aspects of simplicity versus complexity of the surveillance system were assessed by describing data flow, levels of reporting, and data management procedures. Data quality, in terms of data completeness, was evaluated by quantitative indicators, and timeliness was measured in days between different levels of the surveillance system, notification delay, and reporting delay. Trends over time in data quality were analyzed by logistic regression, while negative binomial regression was used to test for trend over time regarding mean notification and reporting delay. RESULTS: Between January 2005 and December 2014, a total of 22,549 AHB infections were reported at the national level. The data flow of the German AHB surveillance system showed structural characteristics of a complex system. Over the 10-year period, completeness of reporting sex, age, probable route of transmission, and hepatitis B virus (HBV) vaccination were 99%, 100%, 25%, and 73%, respectively. However, data quality decreased over the evaluation period. Although notification delay improved over time (incident rate ratio [IRR] = 0.95, 95% confidence interval [CI] = 0.95-0.96; P < 0.05), reporting delay improved only since the amendment (IRR = 0.76, 95% CI = 0.70-0.82; P < 0.05). In total, mean notification and reporting delay were 3.0 days and 14.3 days, respectively. CONCLUSIONS: The German AHB surveillance system is operating in a timely manner. Although timeliness improved over the evaluation period and the amendment to the Protection against Infection Act succeeded in reducing reporting time, data quality in terms of completeness of information decreased considerably. As improved data completeness is required to adequately design prevention activities, reasons for this decrease should further be explored.

Evaluation of the statutory surveillance system for invasive MRSA infections in Germany, 2016-2017.

BACKGROUND: Mandatory notification of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections was introduced for laboratories in Germany in 2009. The aims were to support local health authorities (LHAs) in their mandate to prevent and control infections in hospitals and to improve population-based nationwide surveillance of healthcare associated infections. We evaluated the MRSA surveillance system to assess whether its aims were met and to identify areas for improvement. METHODS: Using the updated guidelines for evaluating public health surveillance systems by the Centers for Disease Control and Prevention we assessed the attributes simplicity, timeliness, data quality, acceptability, and usefulness. In 2016/2017 we interviewed staff in LHAs, state health authorities (SHAs), and laboratories and analyzed surveillance data of cases notified between 2009 and 2016. RESULTS: We interviewed 10% of LHAs (n = 38), 63% of SHAs (n = 10), 5 selected laboratories and analyzed information on 27,706 notified MRSA cases. LHAs reported that on receiving notifications from laboratories they contacted hospitals for clinical information, which was time-consuming and complicated as physicians were hard to reach or refused to answer questions, citing doctor-patient confidentiality. LHAs suggested reducing the amount of information collected as some clinical information was unnecessary for implementing control measures. LHAs stated that they received notifications on time, however surveillance data analysis showed some delay. Data completeness exceeded 90% for most variables, however it was only 68% and 80% for dates of disease onset and hospital admission respectively making it impossible to discriminate between hospital and community acquired infections in half of the cases. The surveillance system was well accepted by half of the interviewees. A third however stated that the benefits of the surveillance system were outweighed by the work associated with it. The majority rated the system to be useful for recognizing trends in the MRSA incidence and the ability to check up on infection control measures in hospitals. CONCLUSIONS: The surveillance system proved to be useful by fulfilling its aims. It was timely, acceptable and provided complete data for most variables. However, the system was complicated; ensuring that only relevant variables are reported could simplify the system without losing any of its usefulness.

Ebola response missions: to go or not to go? Cross-sectional study on the motivation of European public health experts, December 2014.

We surveyed European infectious disease epidemiologists and microbiologists about their decisions to apply for Ebola response missions. Of 368 respondents, 49 (15%) had applied. Applicants did not differ from non-applicants in terms of age, sex or profession but had more training in field epidemiology and more international experience. Common concerns included lack of support from families and employers. Clearer terms of reference and support from employers could motivate application and support outbreak response in West Africa.

[The 2015 edition of case definitions for the surveillance of notifiable infectious diseases in Germany]. / Falldefinitionen für die Surveillance meldepflichtiger Infektionskrankheiten in Deutschland, Ausgabe 2015.

Case definitions ensure standardised criteria for the surveillance of infectious diseases in Germany. Since its last revision in 2007, an update of the complete case definition edition became necessary due to new scientific insights, changes in legislature, terminology and classification systems. At the same time, the case definition should be further standardised and work at local public health authorities should be simplified. The department for infectious disease epidemiology at the Robert Koch Institute (RKI) coordinated the revision of the case definitions. During several feedback sessions, internal RKI experts and external experts from different levels of the German public health system, as well as from medical associations and laboratories, were involved in the revision process. The new edition and an annotated version are published on the RKI website (www.rki.de/falldefinitionen). The new case definitions will become effective on 1st January 2015. The most important changes are summarised in this article.

Transmission of shiga toxin-producing Escherichia coli O104:H4 at a family party possibly due to contamination by a food handler, Germany 2011.

We investigated a cluster of shiga toxin-producing Escherichia coli (STEC) O104:H4 infections after a family party during a large STEC O104:H4 outbreak in Germany. To identify the vehicle we conducted a retrospective cohort study. Stool samples of party guests, and food and environmental samples from the catering company were tested for STEC. We defined cases as party guests with gastrointestinal symptoms and laboratory-confirmed STEC infection. We found 23 cases among 71 guests. By multivariable analysis consumption of salmon [odds ratio (OR) 15, 95% confidence interval (CI) 2.3-97], herb cream (OR 6.5, 95% CI 1.3-33) and bean salad (OR 6.1, 95% CI 1.4-26) were associated with STEC infection. STEC O104:H4 was detected in samples of bell pepper and salmon. The food handler developed STEC infection. Our results point towards transmission via several food items contaminated by a food handler. We recommend regular education of food handlers emphasizing their role in transmitting infectious diseases.