Anja Takla

Carrier Prevalence, Secondary Household Transmission, and Long-Term Shedding in 2 Districts During the Escherichia coli O104:H4 Outbreak in Germany, 2011

BACKGROUND From May through July 2011, Germany experienced a large outbreak of Shiga toxin-producing Escherichia coli (STEC) O104:H4 infection. Our objective was to identify the prevalence of STEC O104:H4 carriers in households in highly affected areas, the rate of secondary household transmissions, and the duration of long-term shedding. METHODS In a cross-sectional study, we recruited case and control households to determine STEC household prevalence. We then conducted a prospective cohort study (households with ≥ 2 members and ≥ 1 case) to determine rates of household transmission and shedding duration. RESULTS For part 1, we recruited 57 case households (62 case patients and 93 household contacts) and 36 control households (89 household members). We only detected cases in previously known case households and identified 1 possible adult-to-adult household transmission. For part 2, we followed 14 households and 20 carriers. No secondary household transmission was detected in the prospective follow-up period. In 1 adult carrier, shedding lasted >7 months. However, the median estimated shedding time was 10-14 days (95% confidence interval, 0-33 days). Three carriers showed intermittent shedding. CONCLUSIONS The prevalence of STEC O104:H4 carriers even in highly affected areas appears to be low. Despite prolonged shedding in some patients, secondary adult-to-adult household transmissions seem to be rare events in the postdiarrheal disease phase.

Mumps epidemiology in Germany 2007-11

In Germany, mumps has been notifiable until 2013 only in the five Eastern federal states (EFS) of former East Germany. Due to different immunisation policies until 1990 and varying vaccination coverages thereafter, mumps incidences cannot be extrapolated to the 11 Western federal states (WFS). We studied mumps-related International Classification of Diseases (ICD-10) code diagnoses claimed through statutory health insurances between 2007 and 2011 to estimate countrywide mumps incidences in the outpatient sector, and compared them with case numbers from ambulatory notification data. Overall, 32,330 outpatient mumps cases were claimed. Annual incidence ranged between 9.3/100,000 and 11.8/100,000 and showed a significant decreasing trend. Compared with EFS, mumps incidence in WFS was higher and indicated a shift towards older age groups. Notified outpatient case numbers in EFS were 13-fold lower and from voluntary surveillance during an outbreak in the WFS Bavaria 8-fold lower than from insurance data (n=316 versus n=4,217 and n=238 versus 1,995, respectively). Of all notified cases with available information, 75.4% (EFS) and 57.6% (Bavaria) were unvaccinated; 6.8% (EFS) and 19.3% (Bavaria) required hospitalisation. In Germany, mumps is still endemic despite decades of vaccination, with considerable underreporting in the established notification systems.

Evidence-based decision-making in infectious diseases epidemiology, prevention and control: matching research questions to study designs and quality appraisal tools.

BackgroundThe Project on a Framework for Rating Evidence in Public Health (PRECEPT) was initiated and is being funded by the European Centre for Disease Prevention and Control (ECDC) to define a methodology for evaluating and grading evidence and strength of recommendations in the field of public health, with emphasis on infectious disease epidemiology, prevention and control. One of the first steps was to review existing quality appraisal tools (QATs) for individual research studies of various designs relevant to this area, using a question-based approach.MethodsThrough team discussions and expert consultations, we identified 20 relevant types of public health questions, which were grouped into six domains, i.e. characteristics of the pathogen, burden of disease, diagnosis, risk factors, intervention, and implementation of intervention. Previously published systematic reviews were used and supplemented by expert consultation to identify suitable QATs. Finally, a matrix was constructed for matching questions to study designs suitable to address them and respective QATs. Key features of each of the included QATs were then analyzed, in particular in respect to its intended use, types of questions and answers, presence/absence of a quality score, and if a validation was performed.ResultsIn total we identified 21 QATs and 26 study designs, and matched them. Four QATs were suitable for experimental quantitative study designs, eleven for observational quantitative studies, two for qualitative studies, three for economic studies, one for diagnostic test accuracy studies, and one for animal studies. Included QATs consisted of six to 28 items. Six of the QATs had a summary quality score. Fourteen QATs had undergone at least one validation procedure.ConclusionsThe results of this methodological study can be used as an inventory of potentially relevant questions, appropriate study designs and QATs for researchers and authorities engaged with evidence-based decision-making in infectious disease epidemiology, prevention and control.

Characteristics and practices of National Immunisation Technical Advisory Groups in Europe and potential for collaboration, April 2014

In many countries, national vaccination recommendations are developed by independent expert committees, so-called national immunisation technical advisory groups (NITAG). Since the evaluation of vaccines is complex and resource-demanding, collaboration between NITAGs that evaluate the same vaccines could be beneficial. We conducted a cross-sectional survey among 30 European countries in February 2014, to explore basic characteristics and current practices of European NITAGs and identify potential modes and barriers for collaboration. Of 28 responding countries, 26 reported to have a NITAG or an equivalent expert group. Of these, 20 apply a systematic approach in the vaccine decision-making process, e.g. by considering criteria such as country-specific disease epidemiology, vaccine efficacy/effectiveness/safety, health economics, programme implementation/logistics or country-specific values/preferences. However, applied frameworks and extent of evidence review differ widely. The use of systematic reviews is required for 15 of 26 NITAGs, while results from transmission modelling and health economic evaluations are routinely considered by 18 and 20 of 26 NITAGs, respectively. Twenty-five countries saw potential for NITAG-collaboration, but most often named structural concerns, e.g. different NITAG structures or countries’ healthcare systems. Our survey gathered information that can serve as an inventory on European NITAGs, allowing further exploration of options and structures for NITAG collaboration.

Measles incidence and reporting trends in Germany, 2007-2011.

Abstract Objective We aimed to quantify progress towards measles elimination in Germany from 2007 to 2011 and to estimate any potential underreporting over this period. Methods We determined the annual incidence of notified cases of measles – for each year – in northern, western, eastern and southern Germany and across the whole country. We then used measles-related health insurance claims to estimate the corresponding incidence. Findings In each year between 2007 and 2011, there were 6.9–19.6 (mean: 10.8) notified cases of measles per million population. Incidence decreased with age and showed geographical variation, with highest mean incidence – 20.3 cases per million – in southern Germany. Over the study period, incidence decreased by 10% (incidence rate ratio, IRR: 0.90; 95% confidence interval, CI: 0.85–0.95) per year in western Germany but increased by 77% (IRR: 1.77; 95% CI: 1.62–1.93) per year in eastern Germany. Although the estimated incidence of measles based on insurance claims showed similar trends, these estimates were 2.0- to 4.8-fold higher than the incidence of notified cases. Comparisons between the data sets indicated that the underreporting increased with age and was generally less in years when measles incidence was high than in low-incidence years. Conclusion Germany is still far from achieving measles elimination. There is substantial regional variation in measles epidemiology and, therefore, a need for region-specific interventions. Our analysis indicates underreporting in the routine surveillance system between 2007 and 2011, especially among adults.

Towards a framework for evaluating and grading evidence in public health.

The Project on a Framework for Rating Evidence in Public Health (PRECEPT) is an international collaboration of public health institutes and universities which has been funded by the European Centre for Disease Prevention and Control (ECDC) since 2012. Main objective is to define a framework for evaluating and grading evidence in the field of public health, with particular focus on infectious disease prevention and control. As part of the peer review process, an international expert meeting was held on 13-14 June 2013 in Berlin. Participants were members of the PRECEPT team and selected experts from national public health institutes, World Health Organization (WHO), and academic institutions. The aim of the meeting was to discuss the draft framework and its application to two examples from infectious disease prevention and control. This article introduces the draft PRECEPT framework and reports on the meeting, its structure, most relevant discussions and major conclusions.

Outbreak-related mumps vaccine effectiveness among a cohort of children and of young adults in Germany 2011

Mumps outbreaks in populations with high 2-dose vaccination coverage and among young adults are increasingly reported. However, data on the duration of vaccine-induced protection conferred by mumps vaccines are scarce. As part of a supra-regional outbreak in Germany 2010/11, we conducted two retrospective cohort studies in a primary school and among adult ice hockey teams to determine mumps vaccine effectiveness (VE). Via questionnaires we collected information on demography, clinical manifestations, and reviewed vaccination cards. We estimated VE as 1-RR, RR being the rate ratio of disease among two-times or one-time mumps-vaccinated compared with unvaccinated persons. The response rate was 92.6% (100/108—children cohort) and 91.7% (44/48—adult cohort). Fourteen cases were identified in the children and 6 in the adult cohort. In the children cohort (mean age: 9 y), 2-dose VE was 91.9% (95% CI 81.0–96.5%). In the adult cohort (mean age: 26 y), no cases occurred among the 13 2-times vaccinated, while 1-dose VE was 50.0% (95% CI –9.4–87.1%). Average time since last vaccination showed no significant difference for cases and non-cases, but cases were younger at age of last mumps vaccination (children cohort: 2 vs. 3 y, P = 0.04; adult cohort: 1 vs. 4 y, P = 0.03). We did not observe signs of waning immunity in the children cohort. Due to the small sample size VE in the adult cohort should be interpreted with caution. Given the estimated VE, very high 2-dose vaccination coverage is required to prevent future outbreaks. Intervention efforts to increase coverage must especially target young adults who received <2 vaccinations during childhood.

The FIFA Women's World Cup in Germany 2011 - A practical example for tailoring an event-specific enhanced infectious disease surveillance system

BackgroundMass gatherings require a decision from public health authorities on how to monitor infectious diseases during the event. The appropriate level of enhanced surveillance depends on parameters like the scale of the event (duration, spatial distribution, season), participants’ origin, amount of public attention, and baseline disease activity in the host country. For the FIFA Men’s World Cup 2006, Germany implemented enhanced surveillance. As the scale of the FIFA Women’s World Cup (June 26 – July 17, 2011) was estimated to be substantially smaller in size, visitors and duration, it was not feasible to simply adopt the previously implemented measures. Our aim was therefore to develop a strategy to tailor an event-specific enhanced surveillance for this smaller-scale mass gathering.MethodsBased on the enhanced surveillance measures during the Men’s Cup, we conducted a needs assessment with the district health authorities in the 9 host cities in March 2011. Specific measures with a majority consent were implemented. After the event, we surveyed the 9 district and their corresponding 7 state health authorities to evaluate the implemented measures.ResultsAll 9 district health authorities participated in the pre-event needs assessment. The majority of sites consented to moving from weekly to daily (Monday-Friday) notification reporting of routine infectious diseases, receiving regular feedback on those notification reports and summaries of national/international World Cup-relevant epidemiological incidents, e.g. outbreaks in countries of participating teams. In addition, we decided to implement twice-weekly reports of “unusual events” at district and state level. This enhanced system would commence on the first day and continue to one day following the tournament. No World Cup-related infectious disease outbreaks were reported during this time period. Eight of 9 district and 6 of 8 state health authorities participated in the final evaluation. The majority perceived the implemented measures as adequate.ConclusionsOur approach to tailor an event-specific enhanced surveillance concept worked well. Involvement of the participating stakeholders early-on in the planning phase secured ownership of and guaranteed support for the chosen strategy. The enhanced surveillance for this event resulted as a low-level surveillance. However, we included mechanisms for rapid upscaling if the situation would require adaptations.

PRECEPT: an evidence assessment framework for infectious disease epidemiology, prevention and control

Decisions in public health should be based on the best available evidence, reviewed and appraised using a rigorous and transparent methodology. The Project on a Framework for Rating Evidence in Public Health (PRECEPT) defined a methodology for evaluating and grading evidence in infectious disease epidemiology, prevention and control that takes different domains and question types into consideration. The methodology rates evidence in four domains: disease burden, risk factors, diagnostics and intervention. The framework guiding it has four steps going from overarching questions to an evidence statement. In step 1, approaches for identifying relevant key areas and developing specific questions to guide systematic evidence searches are described. In step 2, methodological guidance for conducting systematic reviews is provided; 15 study quality appraisal tools are proposed and an algorithm is given for matching a given study design with a tool. In step 3, a standardised evidence-grading scheme using the Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) methodology is provided, whereby findings are documented in evidence profiles. Step 4 consists of preparing a narrative evidence summary. Users of this framework should be able to evaluate and grade scientific evidence from the four domains in a transparent and reproducible way.

Background paper for the recommendation of HPV vaccination for boys in Germany

In June 2018 the German Standing Committee on Vaccination (STIKO) endorsed the following recommendation: The STIKO recommends vaccination of boys aged 9–14 years against human papillomavirus (HPV). Immunization should take place before the first sexual contact. Like HPV vaccination for girls, two vaccine doses at least 5 months apart are needed at the age of 9–14 years. If the first HPV vaccine dose is given at the age of 15 years or older, three vaccine doses are needed. Catch-up vaccination should take place up to the age of 17 years. The aim of vaccinating girls and boys is to reduce the disease burden of HPV-associated tumours. This paper presents the scientific background of this recommendation, including the results of literature reviews and the grading of the quality of the available evidence. A German version of this paper is available in the Epidemiologische Bulletin 26/2018 [1].