Anna Kuehne

Impact and Lessons Learned from Mass Drug Administrations of Malaria Chemoprevention during the Ebola Outbreak in Monrovia, Liberia, 2014

Background In October 2014, during the Ebola outbreak in Liberia healthcare services were limited while malaria transmission continued. Médecins Sans Frontières (MSF) implemented a mass drug administration (MDA) of malaria chemoprevention (CP) in Monrovia to reduce malaria-associated morbidity. In order to inform future interventions, we described the scale of the MDA, evaluated its acceptance and estimated the effectiveness. Methods MSF carried out two rounds of MDA with artesunate/amodiaquine (ASAQ) targeting four neighbourhoods of Monrovia (October to December 2014). We systematically selected households in the distribution area and administered standardized questionnaires. We calculated incidence ratios (IR) of side effects using poisson regression and compared self-reported fever risk differences (RD) pre- and post-MDA using a z-test. Findings In total, 1,259,699 courses of ASAQ-CP were distributed. All households surveyed (n = 222; 1233 household members) attended the MDA in round 1 (r1) and 96% in round 2 (r2) (212/222 households; 1,154 household members). 52% (643/1233) initiated ASAQ-CP in r1 and 22% (256/1154) in r2. Of those not initiating ASAQ-CP, 29% (172/590) saved it for later in r1, 47% (423/898) in r2. Experiencing side effects in r1 was not associated with ASAQ-CP initiation in r2 (IR 1.0, 95%CI 0.49–2.1). The incidence of self-reported fever decreased from 4.2% (52/1229) in the month prior to r1 to 1.5% (18/1229) after r1 (p<0.001) and decrease was larger among household members completing ASAQ-CP (RD = 4.9%) compared to those not initiating ASAQ-CP (RD = 0.6%) in r1 (p<0.001). Conclusions The reduction in self-reported fever cases following the intervention suggests that MDAs may be effective in reducing cases of fever during Ebola outbreaks. Despite high coverage, initiation of ASAQ-CP was low. Combining MDAs with longer term interventions to prevent malaria and to improve access to healthcare may reduce both the incidence of malaria and the proportion of respondents saving their treatment for future malaria episodes.

Migrationshintergrund in der infektionsepidemiologischen Surveillance in Deutschland

ZusammenfassungHintergrundMigration beeinflusst die Epidemiologie von Infektionskrankheiten. Sich daraus ergebende Risikogruppen und Präventionsbedarfe zu identifizieren, ist Grundlage für eine adäquate Gestaltung von Public-Health-Maßnahmen. Es stellt sich die Frage, inwieweit sich migrationsspezifische Informationen hierfür direkt aus der infektionsepidemiologischen Surveillance ableiten lassen.Ziel der ArbeitZiel ist eine systematische Darstellung von Indikatoren zur Operationalisierung des Migrationshintergrundes in der infektionsepidemiologischen Surveillance in Deutschland sowie die Einschätzung bestehender Einschränkungen.MethodikFür meldepflichtige Krankheiten bzw. Erregernachweise werden die jeweils erhobenen Indikatoren für Migration und deren Grundlage im Infektionsschutzgesetz dargestellt. Für Tuberkulose (TB), HIV und Syphilis werden Meldedaten für 2002–2013 deskriptiv analysiert.ErgebnisseBei fünf Infektionskrankheiten wurden – unterschiedlich operationalisiert – Informationen zum Migrationshintergrund erhoben. Bei TB (Geburtsland) und HIV (Herkunftsland) war eine nicht-deutsche Herkunft deutlich häufiger als bei Syphilis (Herkunftsland) mit 46, 30 bzw. 13 % der Fälle mit entsprechenden Angaben. Bei allen drei betrachteten Infektionskrankheiten ergaben sich Hinweise auf migrationsspezifische Risikoprofile.DiskussionEinheitliche Indikatoren für Migration in der infektionsepidemiologischen Surveillance würden die internationale und erregerübergreifende Vergleichbarkeit der Daten ermöglichen. Die Surveillance erlaubt aktuell teilweise migrationssensible Analysen, jedoch bedarf es zusätzlicher Studien, um die komplexen Zusammenhänge von Migration und Infektionskrankheiten richtig interpretieren und Public-Health-Maßnahmen bedarfsgerecht gestalten zu können.AbstractBackgroundMigration is an important factor impacting on infectious disease epidemiology. The timely identification of groups at risk and prevention needs resulting from migration is indispensable to adequately design and implement public health measures. It remains to be assessed to which extent surveillance data for notifiable diseases can directly generate meaningful migration-specific information.ObjectivesThe objectives of this study are to review indicators of migration background utilized in the German infectious disease surveillance, as well as to assess their limitations.MethodsWe describe the indicators of migration used for mandatorily notifiable diseases and pathogens and their legal basis in the Protection against Infection Act and conduct a descriptive analysis of surveillance data for tuberculosis (TB), HIV and syphilis from 2002–2013.ResultsMigration status is collected only for five infectious diseases and operationalization varies. For TB (country of birth) and HIV (country of origin) a foreign origin was more frequent than for syphilis (country of origin); namely 46, 30 and 13 % of cases with available information, respectively. In all three examples, there are indications of risk profiles that are specific for particular groups of migrants.DiscussionA standardization of indicators of migration in infectious disease surveillance is important to enhance data comparability between diseases and pathogens as well as across countries. Routine surveillance already partly allows migration sensitive analyses, yet further research is needed to guide interpretation of the complex relationship between migration and infectious diseases and plan public health measures adequately.BACKGROUND Migration is an important factor impacting on infectious disease epidemiology. The timely identification of groups at risk and prevention needs resulting from migration is indispensable to adequately design and implement public health measures. It remains to be assessed to which extent surveillance data for notifiable diseases can directly generate meaningful migration-specific information. OBJECTIVES The objectives of this study are to review indicators of migration background utilized in the German infectious disease surveillance, as well as to assess their limitations. METHODS We describe the indicators of migration used for mandatorily notifiable diseases and pathogens and their legal basis in the Protection against Infection Act and conduct a descriptive analysis of surveillance data for tuberculosis (TB), HIV and syphilis from 2002-2013. RESULTS Migration status is collected only for five infectious diseases and operationalization varies. For TB (country of birth) and HIV (country of origin) a foreign origin was more frequent than for syphilis (country of origin); namely 46, 30 and 13% of cases with available information, respectively. In all three examples, there are indications of risk profiles that are specific for particular groups of migrants. DISCUSSION A standardization of indicators of migration in infectious disease surveillance is important to enhance data comparability between diseases and pathogens as well as across countries. Routine surveillance already partly allows migration sensitive analyses, yet further research is needed to guide interpretation of the complex relationship between migration and infectious diseases and plan public health measures adequately.

Erratum zu: Ausbrüche von Infektionskrankheiten in Gemeinschaftsunterkünften für Asylsuchende 2004–2014 in Deutschland

Hintergrund Wahrend sich die Verteilung und die Bedeutung einzelner Infektionskrankheiten durch Migrationsbewegungen und importierte Infektionen in Europa verandern, ist der Umfang der Weiterverbreitung von importierten Infektionen innerhalb Europas unbekannt. Asylsuchende konnen besonders vulnerabel fur Infektionen und das Auftreten von Krankheiten sein.

[Migration and infectious disease surveillance in Germany: Analyses of Tuberculosis, HIV and Syphilis surveillance data].

ZusammenfassungHintergrundMigration beeinflusst die Epidemiologie von Infektionskrankheiten. Sich daraus ergebende Risikogruppen und Präventionsbedarfe zu identifizieren, ist Grundlage für eine adäquate Gestaltung von Public-Health-Maßnahmen. Es stellt sich die Frage, inwieweit sich migrationsspezifische Informationen hierfür direkt aus der infektionsepidemiologischen Surveillance ableiten lassen.Ziel der ArbeitZiel ist eine systematische Darstellung von Indikatoren zur Operationalisierung des Migrationshintergrundes in der infektionsepidemiologischen Surveillance in Deutschland sowie die Einschätzung bestehender Einschränkungen.MethodikFür meldepflichtige Krankheiten bzw. Erregernachweise werden die jeweils erhobenen Indikatoren für Migration und deren Grundlage im Infektionsschutzgesetz dargestellt. Für Tuberkulose (TB), HIV und Syphilis werden Meldedaten für 2002–2013 deskriptiv analysiert.ErgebnisseBei fünf Infektionskrankheiten wurden – unterschiedlich operationalisiert – Informationen zum Migrationshintergrund erhoben. Bei TB (Geburtsland) und HIV (Herkunftsland) war eine nicht-deutsche Herkunft deutlich häufiger als bei Syphilis (Herkunftsland) mit 46, 30 bzw. 13 % der Fälle mit entsprechenden Angaben. Bei allen drei betrachteten Infektionskrankheiten ergaben sich Hinweise auf migrationsspezifische Risikoprofile.DiskussionEinheitliche Indikatoren für Migration in der infektionsepidemiologischen Surveillance würden die internationale und erregerübergreifende Vergleichbarkeit der Daten ermöglichen. Die Surveillance erlaubt aktuell teilweise migrationssensible Analysen, jedoch bedarf es zusätzlicher Studien, um die komplexen Zusammenhänge von Migration und Infektionskrankheiten richtig interpretieren und Public-Health-Maßnahmen bedarfsgerecht gestalten zu können.AbstractBackgroundMigration is an important factor impacting on infectious disease epidemiology. The timely identification of groups at risk and prevention needs resulting from migration is indispensable to adequately design and implement public health measures. It remains to be assessed to which extent surveillance data for notifiable diseases can directly generate meaningful migration-specific information.ObjectivesThe objectives of this study are to review indicators of migration background utilized in the German infectious disease surveillance, as well as to assess their limitations.MethodsWe describe the indicators of migration used for mandatorily notifiable diseases and pathogens and their legal basis in the Protection against Infection Act and conduct a descriptive analysis of surveillance data for tuberculosis (TB), HIV and syphilis from 2002–2013.ResultsMigration status is collected only for five infectious diseases and operationalization varies. For TB (country of birth) and HIV (country of origin) a foreign origin was more frequent than for syphilis (country of origin); namely 46, 30 and 13 % of cases with available information, respectively. In all three examples, there are indications of risk profiles that are specific for particular groups of migrants.DiscussionA standardization of indicators of migration in infectious disease surveillance is important to enhance data comparability between diseases and pathogens as well as across countries. Routine surveillance already partly allows migration sensitive analyses, yet further research is needed to guide interpretation of the complex relationship between migration and infectious diseases and plan public health measures adequately.BACKGROUND Migration is an important factor impacting on infectious disease epidemiology. The timely identification of groups at risk and prevention needs resulting from migration is indispensable to adequately design and implement public health measures. It remains to be assessed to which extent surveillance data for notifiable diseases can directly generate meaningful migration-specific information. OBJECTIVES The objectives of this study are to review indicators of migration background utilized in the German infectious disease surveillance, as well as to assess their limitations. METHODS We describe the indicators of migration used for mandatorily notifiable diseases and pathogens and their legal basis in the Protection against Infection Act and conduct a descriptive analysis of surveillance data for tuberculosis (TB), HIV and syphilis from 2002-2013. RESULTS Migration status is collected only for five infectious diseases and operationalization varies. For TB (country of birth) and HIV (country of origin) a foreign origin was more frequent than for syphilis (country of origin); namely 46, 30 and 13% of cases with available information, respectively. In all three examples, there are indications of risk profiles that are specific for particular groups of migrants. DISCUSSION A standardization of indicators of migration in infectious disease surveillance is important to enhance data comparability between diseases and pathogens as well as across countries. Routine surveillance already partly allows migration sensitive analyses, yet further research is needed to guide interpretation of the complex relationship between migration and infectious diseases and plan public health measures adequately.

Find and treat or find and lose? Tuberculosis treatment outcomes among screened newly arrived asylum seekers in Germany 2002 to 2014

Background Germany has a low tuberculosis (TB) incidence. A relevant and increasing proportion of TB cases is diagnosed among asylum seekers upon screening. Aim: We aimed to assess whether cases identified by screening asylum seekers had equally successful and completely reported treatment outcomes as cases diagnosed by passive case finding and contact tracing in the general population. Methods: We analysed characteristics and treatment outcomes of pulmonary TB cases notified in Germany between 2002 and 2014, stratified by mode of case finding. We performed three multivariable analyses with different dependent variables: Model A: successful vs all other outcomes, Model B: successful vs documented non-successful clinical outcome and Model C: known outcome vs lost to follow-up. Results: TB treatment success was highest among cases identified by contact tracing (87%; 3,139/3,591), followed by passive case finding (74%; 28,804/39,019) and by screening asylum seekers (60%; 884/1,474). Cases identified by screening asylum seekers had 2.4 times higher odds of not having a successful treatment outcome as opposed to all other outcomes (A), 1.4 times higher odds of not having a successful treatment outcome as opposed to known non-successful outcomes (B) and 2.3 times higher odds of loss to follow-up (C) than cases identified by passive case finding. Conclusion: Screened asylum seekers had poorer treatment outcomes and were more often lost to follow-up. Linking patients to treatment facilities and investigating potential barriers to treatment completion are needed to secure screening benefits for asylum seekers and communities.

Knowledge, Attitude, Behavior, and Practices Regarding HIV, Viral Hepatitis, and Sexually Transmitted Infections Among Migrants From Sub-Saharan Africa Living in Germany: A Multicenter Survey Protocol

Background Migration has an impact on the epidemiology of viral hepatitis B and C (HEP) and HIV in Germany; migrants from sub-Saharan Africa (MisSA) in Germany are disproportionally affected by HIV. In the last 10 years, a total of 10%-15% of all newly diagnosed HIV cases were among MisSA; 20%-30% of them acquired HIV in Germany. Prevalence of HEP among MisSA in Germany is unknown, but Western Africa, from where most MisSA in Germany originate, reports the highest prevalence of hepatitis B worldwide. There is limited information on knowledge, attitudes, behaviors, and practices (KABP) regarding HIV, HEP, and sexually transmitted infections (STIs), as MisSA are not reached with surveys targeting the general population. Objective Our objective was to determine the HIV, HEP, and STI information and prevention needs of MisSA in Germany. Methods We conducted a multicenter, cross-sectional, KABP survey regarding HIV, HEP, and STIs among MisSA living in Germany using convenience sampling. The study design was developed as a community-based participatory health research (CBPHR) project; HIV/STI-prevention specialists, key persons from MisSA communities, and HIV/STI researchers were involved in all steps of the research process. Trained peer researchers recruited participants in six study cities. Potential modes of survey administration were interview or self-completion, and the questionnaire was available in English, French, and German. Questions on knowledge about HIV, HEP, and STIs were presented as true statements; participants were asked if they had known the information before. Focus groups with MisSA were conducted to interpret results. Data collection took place from October 2014 to November 2016. Results Recruitment by peer researchers concluded with 3040 eligible participants. Data collection was completed in November 2016. We are currently analyzing the quantitative data and qualitative data from focus groups. We are conducting working group meetings to discuss the results in the respective study cities and to evaluate the application of participatory health research in epidemiological studies. First results are expected by the end of 2017. Conclusions Working with peer researchers to collect data allowed accessibility to a diverse sample of MisSA and, particularly, allowed us to reach vulnerable subgroups, such as MisSA without legal status. The ability to access hard-to-reach groups is one of the big advantages of CBPHR. The active inclusion of the persons under study in the design of the study resulted in higher acceptance and ownership of the research project in the target community; this ultimately lead to better quality of collected data. Furthermore, the participation of MisSA in the development of study design and data collection assures a better understanding of the interests, needs, and living conditions of this group.

Mortality, Morbidity and Health-Seeking Behaviour during the Ebola Epidemic 2014-2015 in Monrovia Results from a Mobile Phone Survey

Between March 2014 and July 2015 at least 10,500 Ebola cases including more than 4,800 deaths occurred in Liberia, the majority in Monrovia. However, official numbers may have underestimated the size of the outbreak. Closure of health facilities and mistrust in existing structures may have additionally impacted on all-cause morbidity and mortality. To quantify mortality and morbidity and describe health-seeking behaviour in Monrovia, Médecins sans Frontières (MSF) conducted a mobile phone survey from December 2014 to March 2015. We drew a random sample of households in Monrovia and conducted structured mobile phone interviews, covering morbidity, mortality and health-seeking behaviour from 14 May 2014 until the day of the survey. We defined an Ebola-related death as any death meeting the Liberian Ebola case definition. We calculated all-cause and Ebola-specific mortality rates. The sample consisted of 6,813 household members in 905 households. We estimated a crude mortality rate (CMR) of 0.33/10,000 persons/day (95%CI:0.25–0.43) and an Ebola-specific mortality rate of 0.06/10,000 persons/day (95%-CI:0.03–0.11). During the recall period, 17 Ebola cases were reported including those who died. In the 30 days prior to the survey 277 household members were reported sick; malaria accounted for 54% (150/277). Of the sick household members, 43% (122/276) did not visit any health care facility. The mobile phone-based survey was found to be a feasible and acceptable alternative method when data collection in the community is impossible. CMR was estimated well below the emergency threshold of 1/10,000 persons/day. Non-Ebola-related mortality in Monrovia was not higher than previous national estimates of mortality for Liberia. However, excess mortality directly resulting from Ebola did occur in the population. Importantly, the small proportion of sick household members presenting to official health facilities when sick might pose a challenge for future outbreak detection and mitigation. Substantial reported health-seeking behaviour outside of health facilities may also suggest the need for adapted health messaging and improved access to health care.

Impact of HIV knowledge and stigma on the uptake of HIV testing – Results from a community-based participatory research survey among migrants from sub-Saharan Africa in Germany

Background In 2015, 3,674 new HIV diagnoses were notified in Germany; 16% of those newly diagnosed cases originated from sub-Saharan Africa (sSA). One quarter of the newly diagnosed cases among migrants from sSA (MisSA) are notified as having acquired the HIV infection in Germany. In order to reach MisSA with HIV testing opportunities, we aimed to identify which determinants influence the uptake of HIV testing among MisSA in Germany. Methods To identify those determinants, we conducted a quantitative cross-sectional survey among MisSA in Germany. The survey was designed in a participatory process that included MisSA and other stakeholders in HIV-prevention. Peer researchers recruited participants to complete standardized questionnaires on HIV knowledge and testing. We conducted multivariable analyses (MVA) to identify determinants associated with ever having attended voluntary HIV testing; and another MVA to identify determinant associated with having had the last voluntary HIV test in Germany. Results Peer researchers recruited 2,782 participants eligible for inclusion in the MVA. Of these participants, 59.9% (1,667/2,782) previously had an HIV test. For each general statement about HIV that participants knew prior to participation in the study, the odds of having been tested increased by 19% (OR 1.19; 95%-CI: 1.11–1.27). Participants reporting that HIV is a topic that is discussed in their community had 92% higher odds of having been tested for HIV (OR 1.92; 95%-CI: 1.60–2.31). Migrants living in Germany for less than a year had the lowest odds of having had their last HIV test in Germany (OR 0.17; 95%-CI: 0.11–0.27). Additionally, MisSA 18 to 25 years (OR 0.55; 95%-CI: 0.42–0.73) and participants with varied sexual partners and inconsistent condom use (OR 0.75; 95%-CI: 0.44–0.97) had significantly lower odds of having had their last HIV test in Germany. Discussion Through participatory research, we were able to show that knowledge about HIV and discussing HIV in communities increased the odds of having attended HIV testing among MisSA. However, recent migrants and young sexually active people are among the least reached by testing offers in Germany. Community-based interventions may present opportunities to reach such migrants and improve knowledge and increase discussion about HIV.

Migrationshintergrund in der infektionsepidemiologischen Surveillance in Deutschland@@@Migration and infectious disease surveillance in Germany: Analysen am Beispiel Tuberkulose, HIV und Syphilis@@@Analyses of Tuberculosis, HIV and Syphilis surveillance data

ZusammenfassungHintergrundMigration beeinflusst die Epidemiologie von Infektionskrankheiten. Sich daraus ergebende Risikogruppen und Präventionsbedarfe zu identifizieren, ist Grundlage für eine adäquate Gestaltung von Public-Health-Maßnahmen. Es stellt sich die Frage, inwieweit sich migrationsspezifische Informationen hierfür direkt aus der infektionsepidemiologischen Surveillance ableiten lassen.Ziel der ArbeitZiel ist eine systematische Darstellung von Indikatoren zur Operationalisierung des Migrationshintergrundes in der infektionsepidemiologischen Surveillance in Deutschland sowie die Einschätzung bestehender Einschränkungen.MethodikFür meldepflichtige Krankheiten bzw. Erregernachweise werden die jeweils erhobenen Indikatoren für Migration und deren Grundlage im Infektionsschutzgesetz dargestellt. Für Tuberkulose (TB), HIV und Syphilis werden Meldedaten für 2002–2013 deskriptiv analysiert.ErgebnisseBei fünf Infektionskrankheiten wurden – unterschiedlich operationalisiert – Informationen zum Migrationshintergrund erhoben. Bei TB (Geburtsland) und HIV (Herkunftsland) war eine nicht-deutsche Herkunft deutlich häufiger als bei Syphilis (Herkunftsland) mit 46, 30 bzw. 13 % der Fälle mit entsprechenden Angaben. Bei allen drei betrachteten Infektionskrankheiten ergaben sich Hinweise auf migrationsspezifische Risikoprofile.DiskussionEinheitliche Indikatoren für Migration in der infektionsepidemiologischen Surveillance würden die internationale und erregerübergreifende Vergleichbarkeit der Daten ermöglichen. Die Surveillance erlaubt aktuell teilweise migrationssensible Analysen, jedoch bedarf es zusätzlicher Studien, um die komplexen Zusammenhänge von Migration und Infektionskrankheiten richtig interpretieren und Public-Health-Maßnahmen bedarfsgerecht gestalten zu können.AbstractBackgroundMigration is an important factor impacting on infectious disease epidemiology. The timely identification of groups at risk and prevention needs resulting from migration is indispensable to adequately design and implement public health measures. It remains to be assessed to which extent surveillance data for notifiable diseases can directly generate meaningful migration-specific information.ObjectivesThe objectives of this study are to review indicators of migration background utilized in the German infectious disease surveillance, as well as to assess their limitations.MethodsWe describe the indicators of migration used for mandatorily notifiable diseases and pathogens and their legal basis in the Protection against Infection Act and conduct a descriptive analysis of surveillance data for tuberculosis (TB), HIV and syphilis from 2002–2013.ResultsMigration status is collected only for five infectious diseases and operationalization varies. For TB (country of birth) and HIV (country of origin) a foreign origin was more frequent than for syphilis (country of origin); namely 46, 30 and 13 % of cases with available information, respectively. In all three examples, there are indications of risk profiles that are specific for particular groups of migrants.DiscussionA standardization of indicators of migration in infectious disease surveillance is important to enhance data comparability between diseases and pathogens as well as across countries. Routine surveillance already partly allows migration sensitive analyses, yet further research is needed to guide interpretation of the complex relationship between migration and infectious diseases and plan public health measures adequately.BACKGROUND Migration is an important factor impacting on infectious disease epidemiology. The timely identification of groups at risk and prevention needs resulting from migration is indispensable to adequately design and implement public health measures. It remains to be assessed to which extent surveillance data for notifiable diseases can directly generate meaningful migration-specific information. OBJECTIVES The objectives of this study are to review indicators of migration background utilized in the German infectious disease surveillance, as well as to assess their limitations. METHODS We describe the indicators of migration used for mandatorily notifiable diseases and pathogens and their legal basis in the Protection against Infection Act and conduct a descriptive analysis of surveillance data for tuberculosis (TB), HIV and syphilis from 2002-2013. RESULTS Migration status is collected only for five infectious diseases and operationalization varies. For TB (country of birth) and HIV (country of origin) a foreign origin was more frequent than for syphilis (country of origin); namely 46, 30 and 13% of cases with available information, respectively. In all three examples, there are indications of risk profiles that are specific for particular groups of migrants. DISCUSSION A standardization of indicators of migration in infectious disease surveillance is important to enhance data comparability between diseases and pathogens as well as across countries. Routine surveillance already partly allows migration sensitive analyses, yet further research is needed to guide interpretation of the complex relationship between migration and infectious diseases and plan public health measures adequately.