Effects of a Brief Web-Based "Social Norms"-Intervention on Alcohol, Tobacco and Cannabis Use Among German University Students: Results of a Cluster-Controlled Trial Conducted at Eight Universities.

Background and Aim: "Social norms" (SN)-interventions are aimed at changing existing misperceptions regarding peer substance use by providing feedback on actual norms, thereby affecting personal substance use. It is unknown whether SN-intervention effects previously demonstrated in US students can be replicated in German students. The aim of the INSIST-study was to examine the effects of a web-based SN-intervention on substance use. Design: Cluster-controlled trial. Setting: Eight Universities in Germany. Participants and Measurements: Students were recruited at four intervention vs. four delayed intervention control Universities. 4,463 students completed baseline, 1,255 students (59% female) completed both baseline and 5-months follow-up web-based surveys on personal and perceived peer substance use. Intervention participants received feedback contrasting personal and perceived peer use with previously assessed use and perceptions of same-sex, same-university peers. Intervention effects were assessed via multivariable mixed logistic regression models. Findings: Relative to controls, reception of SN-feedback was associated with higher odds for decreased alcohol use (OR: 1.91, 95% CI 1.42-2.56). This effect was most pronounced in students overestimating peer use at baseline and under or accurately estimating it at follow-up (OR: 6.28, 95% CI 2.00-19.8). The OR was 1.33 (95% CI 0.67-2.65) for decreased cannabis use in students at intervention Universities and was statistically significant at 1.70 (95% CI 1.13-2.55) when contrasting unchanged and decreased with increased use. Regarding tobacco use and episodes of drunkenness, no intervention effects were found. Conclusions: This study was the first cluster-controlled trial suggesting beneficial effects of web-based SN-intervention on alcohol and cannabis use in a large sample of German University students. Clinical Trial Registration: The trial registration number of the INSIST-study is DRKS00007635 at the "German Clinical Trials Register."

Assessment of core activities and supportive functions for the communicable diseases surveillance system in Khartoum state, Sudan, 2005-2007.

We conducted a descriptive, retrospective, cross-sectional study to assess the core activities and supportive functions of the communicable diseases surveillance system (CDSS) in Khartoum state, Sudan, for the period 2005-2007. This is the first assessment conducted for CDSS in Khartoum state. The CDSS was studied in terms of core activities and supportive functions. We found that knowledge of the system was 100% at all levels. Data reporting was over the recommended standard of 80% at all levels. Data analysis, epidemic preparedness and feedback were below the recommended standard. All assigned CDSS staff members were trained. Lower levels lacked modern technologies for data reporting and analysis. The CDSS system in Khartoum state is centralized; moreover, the system has not been updated, it is poorly documented and has a shortage of staff at lower levels.

Feasibility of implementing recommendations to improve communicable diseases surveillance--a modified Delphi study.

BACKGROUND: Effective control of communicable diseases requires an effective disease surveillance system (CDSS) which provides information for action on priority communicable diseases. It is the basis for public health decision-making worldwide. Implementation of any public health recommendations for improving a disease surveillance system depends on the acceptability of such recommendations by the relevant stakeholders and the feasibility of implementing the recommendations in practice. OBJECTIVES: The aim of this study was to assess the acceptability and the feasibility of recommended improvements in CDSS among relevant stakeholders in Khartoum state. METHODS: A Delphi consensus process was used in the form of three analytical written rounds and individual face-to-face discussions among relevant stakeholders in Khartoum state to study the feasibility of the recommended improvements in CDSS in Khartoum state. RESULTS: The stakeholders in Khartoum state agreed with most of our statements to improve the CDSS core activities, supportive functions and quality in Khartoum State, and that the existing CDSS in Khartoum state needs to be strengthened with more effective coordination at different levels. Regarding the feasibility of implementing our recommendations, the results of our Delphi survey suggest neither expanding CDSS system, nor including vertical programmes; formulation of updated objectives; improving data management and feedback; strengthening epidemic management, as well as the quality of the system in terms of timeliness, completeness and acceptability. CONCLUSION: This study added strength to our recommendations, based on two previous studies assessing the CDSS in Khartoum state. The Ministry of Health in Khartoum state can implement our consensus recommendations to improve the CDSS system in the future in order to achieve its targeted goals.

Staff views about the quality of the Communicable Diseases Surveillance System in Khartoum State, Sudan, 2005-2007: a qualitative study.

Surveillance staff are vital to the success of surveillance of infectious diseases. In this study, we interviewed staff of the Communicable Diseases Surveillance System (CDSS) in Khartoum state individually and in focus groups to assess their views about the quality of the system for the years 2005-07. The quality of CDSS was considered poor because the system was not representative as it included neither the private nor military sectors nor the important teaching hospitals. It also lacked timeliness due to poor documentation, was inflexible since it did not rapidly respond to emerging and re-emerging diseases such as SARS and avian flu in its notification lists, and it did not use the data collected to apply interventions for control and prevention of communicable diseases on a routine basis. While staff were committed to the surveillance system and felt they worked hard, they were also demotivated and in the long run this might affect their performance.

Familial factors and suicide: an adoption study in a Swedish National Cohort.

BACKGROUND: Parental characteristics influence the risk of offspring suicide. In this study we wanted to separate the hereditary from the environmental influence of such factors by comparing their effects in the adopted versus non-adopted. METHOD: A register study was conducted in a national cohort of 2,471,496 individuals born between 1946 and 1968, including 27,600 national adoptees, followed-up for suicide during 1987-2001. Cox regression was used to calculate hazard ratios (HR) for suicide of socio-economic indicators of the childhood household and biological parents' suicide, alcohol abuse and psychiatric morbidity separately in the adopted and non-adopted. Differences in effects were tested in interaction analyses. RESULTS: Suicide and indicators of severe psychiatric disorder in the biological parents had similar effects on offspring suicide in the non-adopted and adopted (HR 1.5-2.3). Biological parents' alcohol abuse was a risk factor for suicide in the non-adopted group only (HR 1.8 v. 0.8, interaction effect: p=0.03). The effects of childhood household socio-economic factors on suicide were similar in adopted and non-adopted individuals, with growing up in a single parent household [HR 1.5 (95% confidence interval 1.4-1.5)] as the most important socio-economic risk factor for the non-adopted. CONCLUSIONS: The main familial effects of parental suicide and psychiatric morbidity on offspring suicide are not mediated by the post-natal environment or imitation, in contrast to effects of parental alcohol abuse that are primarily mediated by the post-natal environment. Social drift over generations because of psychiatric disorders does not seem likely to explain the association of socio-economic living conditions in childhood to suicide.

Staff views about the quality of the communicable diseases surveillance system in Khartoum state, Sudan, 2005-2007: a qualitative study

Surveillance staff are vital to the success of surveillance of infectious diseases. In this study, we interviewed staff of the Communicable Diseases Surveillance System [CDSS] in Khartoum state individually and in focus groups to assess their views about the quality of the system for the years 2005-07. The quality of CDSS was considered poor because the system was not representative as it included neither the private nor military sectors nor the important teaching hospitals. It also lacked timeliness due to poor documentation, was inflexible since it did not rapidly respond to emerging and re-emerging diseases such as SARS and avian flu in its notification lists, and it did not use the data collected to apply interventions for control and prevention of communicable diseases on a routine basis. While staff were committed to the surveillance system and felt they worked hard, they were also demotivated and in the long run this might affect their performance

Developing policy options for SARS and SARS-like diseases - a Delphi study.

The objective of the SARSControl Delphi study was to develop options for national and international emerging infectious diseases policies. The aim of this paper is to present the results of the study, which gathered expert opinions on gaps and inconsistencies concerning preparedness and response planning for Severe Acute Respiratory Syndrome (SARS) and SARS-like diseases. The Delphi technique was employed, which comprised a pilot round, two written rounds and a face-to-face meeting. The Delphi panel consisted of 38 experts from 22 countries, who highlighted the necessity to test plans and stressed the importance of surveillance measures for the swift containment of communicable disease outbreaks and the inclusion of detailed triage plans in national pandemic plans. The experts also suggested a need to define criteria for testing pandemic preparedness plans at different regional levels. New policy alternatives were identified, such as the need for generic plans on pandemics and universal access to healthcare during an outbreak. The usefulness of some non-medical interventions, such as bans on travel, could not be established and need further research. Dissemination of the findings will help to bridge gaps and rectify inconsistencies in current pandemic planning and response strategies for SARS and SARS-like diseases, as well as add valuable knowledge towards the development of national and international emerging infectious disease policies.

Assessment of core activities and supportive functions for the communicable diseases surveillance system in Khartoum state, Sudan, 2005-2007

We conducted a descriptive, retrospective, cross-sectional study to assess the core activities and supportive functions of the communicable diseases surveillance system [CDSS] in Khartoum state, Sudan, for the period 2005-2007. This is the first assessment conducted for CDSS in Khartoum state. The CDSS was studied in terms of core activities and supportive functions. We found that knowledge of the system was 100% at all levels. Data reporting was over the recommended standard of 80% at all levels. Data analysis, epidemic preparedness and feedback were below the recommended standard. All assigned CDSS staff members were trained. Lower levels lacked modern technologies for data reporting and analysis. The CDSS system in Khartoum state is centralized; moreover, the system has not been updated, it is poorly documented and has a shortage of staff at lower levels

[Prevention and control of infectious diseases with pandemic potential: the EU-project SARSControl]. / Prävention und Kontrolle von pandemischen Infektionskrankheiten: Das EU-Projekt SARSControl.

INTRODUCTION: The influenza pandemics of the 20th century, the SARS epidemic in 2002/03 and the growing number of human cases infected with the H5N1 avian influenza virus clearly demonstrate that the threat of new pandemics is very real. These events have intensified pandemic prevention and control activities worldwide. "SARSControl" is a three-year project funded by the European Commission with the objective to aid European member states in the public health management of new emerging infections. This article summarises the main research results and recommendations arising from this project. METHOD: The reports and papers published in the SARSControl project form the basis of this article. In addition, a literature search for SARS and pandemic influenza was conducted and information on pandemic planning and management guidelines obtained from the WHO and EU websites. The project results are discussed in this context. RESULTS: A lack of knowledge and delayed international communication resulted in the rapid spread of SARS, highlighting the importance of a global system for rapid and transparent information transfer. Epidemiological and economic modelling studies have shown that, in comparison to travel restrictions, applying intervention measures to interrupt local transmission within a country and investing into vaccine research and anti-viral stockpiling, is a more cost-effective and efficient use of resources for the containment of pandemics. A study investigating the perceived threat associated with pandemics showed that the subjective risk perception of people varies among countries. This influences human behaviour and should hence be considered during risk communication and implementation of pandemic control measures. DISCUSSION: The basic prerequisites of an efficient pandemic management are operationalisable pandemic plans, subjected to regular exercises, backed by adequate resources and a sound health-care infrastructure. At international level cross-border co-operation and information exchange on infection control is the key to pandemic mitigation and containment. Strengthening surveillance systems at the international level, to allow the timely monitoring of infectious agents and outbreaks is essential. Transferring such outbreak information in real time into mathematical models and the resulting essential epidemiological information to policy makers would facilitate a more efficient use of scarce resources. Involvement of the public in decisions regarding the implementation of restrictive control measures which often curtail individual liberty is necessary for the acceptance and ultimate success of pandemic control.

Review article: communicable diseases surveillance lessons learned from developed and developing countries: literature review.

BACKGROUND: Surveillance of infectious diseases is recognized as the cornerstone of public health decision-making and practice. The aim of the evaluation of communicable diseases surveillance systems (CDSS) is ensuring that communicable diseases are monitored efficiently and effectively. The aim of this paper is to reflect on the experiences of both developed and developing countries in the evaluation of CDSS in order to learn lessons from these experiences to improve systems everywhere. METHODS: A literature review of studies published in English in PubMed and databases of the World Health Organization (WHO), and Center of Diseases Control (CDC) from 1981 to 2007 was undertaken assessing CDSS. The studies were divided into those from developed and developing countries. RESULTS: A total of 32 studies were included, 20 from developed and twelve from developing countries. Both developed and developing countries faced difficulties in CDSS. Studies from the developed countries have been analysed based on the quality of the system alone. In developing countries, most of the studies have been on the integrated diseases surveillance (IDSR) and have been performed shortly after the adoption of the IDSR. Thus it might be too early to make a fair evaluation. Some of the systems over-centralized, while some lacked private health sector involvement in the system. Further, some of the systems were affected by conflicts and civil wars which are common problems in developing countries. CONCLUSIONS: None of the countries had ideal CDSS. The strategy of integrated diseases surveillance seems to be functioning well especially in Africa.

Longitudinal study of meningococcal carrier rates in teenagers.

To gain actual information concerning the oropharyngeal carriage of Neisseria meningitidis among teenagers aged 15-18 years in Germany especially in a region with increased incidence of meningococal-related diseases prompted the study. Each teenager was swabbed three times with an interval of 2 months between the examinations. The 901 recovered N. meningitidis strains were characterized using serological (serogrouping, serotyping/serosubtyping) and molecular methods (PCR, PFGE) each. The results of the study demonstrate an overall average carrier rate of 18.8% for the three collection periods. There were, however, significant differences between the carrier rates within a given school and of different towns and counties. Of all isolates, 60.6% were not serogroupable. Serogroup B dominated (12.3%), followed by serogroup Y (9.0%) and serogroup C (3.6%). After PCR-based serogrouping of not serogroupable strains the percentages for serogroups enhanced to 18.8% for B, 10.8% for Y and 4.1% for C. Serotyping led to 305 different phenotypes with the most common being 29E:NT:P1.2,5 followed by Y:14:NST. In the 6 study towns the number of different N. meningitidis clones (PFGE types) isolated, varied between 30 and 87. In Wenden, where a prolonged outbreak had taken place, serogroup C (14.8%) was predominant. Only in this town C:2a isolates were found, all belonging to the ST-11/ET-37 complex and 12/13 matched identically to the ET-15 clone. Of the colonized teenagers, 26.7% were carriers over at least 23 weeks, 22.6% with the same strain, 36.0% were carrier for at least 15 weeks. Over all three collection periods 36.7% of the adolescents acquired a new strain. The highest acquisition rate was related to PFGE type 12.

Mobile diabetes education and care: intervention for children and young people with Type 1 diabetes in rural areas of northern Germany.

AIMS: To improve the quality of care in children with Type 1 diabetes who have limited access to specialized diabetes care in rural areas, by providing a mobile diabetes education and care team, affiliated with a University hospital paediatric diabetes centre. METHODS: A cohort of 107 children and their families from eight rural hospitals was followed between July 2000 and July 2002. Parameters on quality of metabolic control (HbA(1c), hospitalization rate and number of episodes of severe hypoglycaemia), diabetes knowledge and quality of life at baseline (t(0)), 6 weeks (t(1)) and 6 months (t(2)) after the interventions were measured. RESULTS: Mean HbA(1c) was 7.9 +/- 1.4% at t(0). The proportion of HbA(1c) values < 6.8% increased significantly (P < 0.05) and of values > 8.0% decreased significantly (P < 0.01) at t(1) and t(2). The rate of hospitalization fell significantly by 9.4%, from 16.2% at baseline to 6.8% at t(2) (P < 0.05). The children reported significantly better diabetes-specific quality of life (P < 0.05) and higher self-esteem (P < 0.01) after the intervention. Theoretical diabetes knowledge was increased both in the short and long term (P < 0.05). CONCLUSIONS: The intervention improved metabolic control, diabetes knowledge and diabetes-specific quality of life. We conclude that high-quality diabetes care in a rural area can be provided by a mobile diabetes education and care team.

[Methods of infectious disease epidemiology for public health services: case control studies as bridge between practical work, surveillance and epidemiology]. / Infektionsepidemiologische Methoden für den OGD: Fall-Kontrollfall-Vergleiche als Brücke zwischen Praxis, Surveillance und Epidemiologie.

Routine surveillance of infectious diseases is one important task of national public health services. Due to globalization the impact of international disease monitoring rises. The volume of traffic and trade is constantly increasing, which makes a spread of infectious diseases to distant places more likely then ever. This are challenges international infectious disease networks have to deal with. Thus, the role of investigation of disease outbreaks is not only relevant for local level; it furthermore prevents broader spread. To eliminate outbreak sources good epidemiological analyses have to be conducted. However, this often leads to extra time and personal resources. In addition classical studies, like case-control studies, underlay methodical limitations. Case-control studies, especially if conducted on the basis of notified cases from surveillance data, are susceptible to bias (like selection- and recall bias). Another study design, the case-case study (case-case comparison), provides an alternative, which is less affected by such limitations. In this approach a number of cases related within an outbreak, is compared with a group of infected individuals of the same disease, not belonging to the outbreak. Results from recently published studies lead to the assumption that this study design is adequate for the investigation of infectious disease outbreaks, captured by surveillance systems. The practical application of this study design makes it especially useful for local public health services and thus provides a bridge between surveillance, epidemiology and practical work in Public Health.

Applying a case-crossover study design to examine transient exposures in the transmission of N. meningitidis.

BACKGROUND: Meningococcal disease is a serious public health problem with a case fatality of about 10%. Recent acquisition of the bacteria is generally regarded as an important risk factor for developing the invasive disease. A case-crossover study to examine the effect of transient exposures on the acute outcome, which is the acquisition of Neisseria meningitidis, was undertaken. METHODS: In the case-crossover design each case serves as its own matched control while case-times are compared to earlier time periods. Data from a longitudinal study was used for a case-crossover analysis. About 1910 students aged 14-19 were tested for meningococcal carriage and interviewed about potential risk factors. About 121 matched pairs of students who were non-carriers in the first survey and became carriers in the second were analysed. Mantel Haenszel Odds Ratios were calculated and a conditional logistic regression analysis was done. RESULTS: Both bivariate and multivariate analysis showed a significant association between meningococcal carriage and the predicting variables rhinitis, visits to cinema, and travelling abroad. While the adjusted results for rhinitis (OR: 0.33; 95% CI: 0.13-0.82) and cinema visits (OR: 0.17; 95% CI: 0.05-0.65) indicate a protective association, travelling abroad (OR: 3.50; 95% CI: 1.45-8.34) turned out as a risk factor. CONCLUSIONS: Transient exposures that trigger the infection with N. meningitidis are generally difficult to study. This case crossover study allows new insights in this process. For the interpretation of the results methodological issues and potential confounding (e.g., seasonal variation) need to be taken into account, especially while comparing the results with those from studies with traditional designs.

[Vaccinations in early infancy -- results of an epidemiological cross-sectional study in Hamburg]. / Impfungen im frühen Kindesalter - Ergebnisse einer epidemiologischen Querschnittstudie in Hamburg.

BACKGROUND: National recommendations for vaccine policies in Germany were changed in 2001. Following this advice childhood vaccination for nine preventable diseases including measles, mumps, and rubella (MMR) should be completed within the first two years of life. To achieve this it is recommended that plurivalent combination vaccines should be used. As data on current practice is generally rare and not available for the State of Hamburg, a cross-sectional study amongst families from Hamburg with children born during the year 2000 was conducted between April and August 2003. METHODS: A random sample from the resident register was drawn. Structured telephone interviews were conducted. Information on vaccine status and time of vaccination was collected based on individual vaccination documents. RESULTS: 366 families were included in the study. 286 families (78 %) provided information. For 223 families the statements were reliably confirmed. In this group 180 children (80.7 % CI 76 - 86 %) had received at least one dose of MMR vaccine. 112 (50.2 % CI 44 - 57 %) had received two doses. Within the recommended time intervals 49 % had received the first, respectively 46 % had received the second MMR vaccination. A hexavalent contains vaccine containing the other six antigens was used for 138 of the 223 children (62 % CI 55 - 68 %). For 84 of those children (61 %) vaccination was completed with four doses. For 73 children other combinations including single valent vaccines were used. Among those for only 20 children (27.3 %) a completed vaccination status was reached during the recommended time interval. This gap was mainly due to missing hepatitis B vaccinations. The chance for their vaccination to be completed was more than twice as high for children who received the hexavalent combination vaccine compared to the others (RR 2.5; 95 % CI 1.6 - 3.9). DISCUSSION: The results indicate that the recommendations to complete MMR vaccinations earlier are recognised. Nevertheless about half of the children were vaccinated later than recommended. In order to achieve vaccination coverage which will allow to achieve the goal of measles eradication substantial efforts are still required. Due to relatively large rates of incomplete vaccinations for the other antigens activities should focus on a timely completion of the gaps. The potential of combination vaccines to reach this aim is evident.

[The influence exercised by the spouse or partner on diabetics--assessing the participation of spouses or lifelong associates in intensive inpatient training--an epidemiological study]. / Einfluss des Lebenspartners von Diabetikern--Evaluation der Teilnahme von Lebenspartnern an einer stationären Diabetes-Intensivschulung anhand einer epidemiologischen Studie.

BACKGROUND: The purpose of this study was to analyse whether participation of spouses of patients with type-2 diabetes in a patient empowerment programme would result in improved metabolic control of diabetes. Values of glycated haemoglobin levels were used for the between-group comparisons. METHODS: This investigation was conducted as a cohort study in which 59 patients with type-2 diabetes participated. Follow-up data were checked after 12 months. We investigated the relative glycated haemoglobin levels, blood pressure, hypoglycaemia, hospitalisation, and weight at baseline and follow-up. The statistical analyses were performed using the software packages SPSS 10 and Epi Info 6. RESULTS: The studied group had an average duration of diabetes of 10.7 years (range 1.3-40.8 years) and an age of 64 years (range 40-79 years). The group accompanied by their spouses did show a significant reduction of the average glycated haemoglobin level from 1.51 to 1.28 (p = 0.0001). By contrast, the reduction of 0.03 in the group without spouses was not significant (p = 0.558). Looking at the relative risk, it turned out that patients without spouses have a 2.3 times higher risk of developing a worse metabolic control after one year than patients with spouses. The logistical regression supported this trend. CONCLUSIONS: This study indicates that the participation of spouses of patients with type-2 diabetes in a patient empowerment programme contributes to an improvement in blood glucose control.

Infectious disease surveillance in North Rhine-Westphalia: first steps in the development of an early warning system.

It is often difficult to detect warning signals on infectious disease outbreaks from raw surveillance data. Data need to be used for a timely generation and distribution of information on the current state of infectious diseases. This offers the opportunity to detect outbreaks and to initiate preventive measures. To improve the surveillance system in North Rhine-Westphalia we have introduced an infectious disease barometer, a simple tool based on weekly notification data. The aim of this tool is not to provide in depth data analysis, but to help to detect clusters or outbreaks. This can be the first step in the development of an early warning system and can support epidemiological investigation and policy making.