Dorothea Matysiak-Klose

Comparative varicella vaccine effectiveness during outbreaks in day-care centres

BACKGROUND Routine varicella vaccination for children >11 months was introduced in Germany in 2004 with three different vaccine brands available. In 2008 and 2009, we investigated seven varicella outbreaks in day-care centres (DCC). METHODS Varicella disease and vaccination status of 1084 children was reviewed to evaluate vaccination coverage (VC), brand-specific varicella vaccine effectiveness (VE), and risk factors of breakthrough varicella (BV, >42 days after vaccination). A case was defined as a child with acute onset of varicella attending one of the respective DCC at the time of outbreak. Children with a previous history of varicella, age<11 months, vaccinated at age<11 months or <42 days before disease onset or during the outbreak were excluded from VE and BV risk factors analyses (adjusted for gender, age and DCC). FINDINGS Of 631 children with available vaccination information, 392 (62%) were vaccinated at least once. Overall VE among 352 children eligible was 71% (95% confidence interval (CI) 57-81, p<0.001) and differed significantly by disease severity and number of doses administered. Risk for BV was higher for 1 dose of Varilrix (RR=2.8, 95%CI 1.0-7.8, p=0.05) or Priorix-Tetra (RR=2.4, 95%CI 0.7-8.3, p=0.18) but lower for 2 doses of Priorix-Tetra (RR=0.5, 95%CI 0.1-2.7, p=0.41) than for 1 dose of Varivax. INTERPRETATION Enhanced efforts to increase VC in Germany and 2 doses varicella vaccine might be successful to reduce the risk for BV. The evidence that VE and risk of BV are associated with vaccine brand needs further investigation.

Closer to the Goal: Efforts in Measles Elimination in Germany 2010

Increasing 2-dose vaccination coverage has led to an interruption of endemic measles virus circulation in Germany. However, outbreaks after virus importation still occur and contribute to international transmission chains. Between 2003 and 2009, annual measles incidence ranged between 0.2 and 2.8 per 100,000 population. Immunization gaps have been identified especially in secondary-school students and young adults, which is also reflected by a shift in age distribution of reported measles cases toward older age groups. Stronger political commitment and standardized guidelines for outbreak containment were put in place in Germany in the past years, but the last step toward measles elimination cannot be made until the number of susceptible individuals has been further reduced. In addition to routine childhood vaccination, supplementary immunization activities are needed targeting school students and young adults to close critical immunization gaps. Intensification of public awareness and sound information on vaccinations are necessary to convince skeptics and remind the forgetful.

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.

Pertussis-Impfquoten bei Erwachsenen in Deutschland

BACKGROUND Pertussis vaccination for risk-groups (e. g. healthcare workers, employees of communal facilities, or persons with close contact to infants) has been recommended in Germany since 2001. In 2009, single-dose acellular pertussis (ap) vaccination was recommended for all adults at the next tetanus-diphtheria (Td) booster. Study aims were to assess 1) pertussis vaccination coverage in adults, and 2) use of tetanus-containing combination vaccines in hospitals. METHODS For 1) we analysed data from two population-based telephone surveys conducted among adults in Germany in 2009/2010 (GEDA09: n = 21,262; GEDA10: n = 22,050). Factors associated with vaccination were identified by logistic regression analyses. For 2) a questionnaire survey of 133 hospital pharmacies serving 454 German hospitals was undertaken for the year 2007. RESULTS Overall, 5.9% (95% confidence interval [CI] 5.5-6.3%) of GEDA10 participants reported up-to-date pertussis vaccination (ap-vaccination in past 10 years). In risk-groups, vaccination coverage was 10.7% (95%-CI 9.8-11.7%). Residence in former East-Germany and younger age were independently associated with an adequate vaccination status. Contrary to prevailing recommendations, ~75% of tetanus vaccines were administered as monovalent rather than Td- (or Tdap-)combination vaccines in hospitals. CONCLUSIONS In light of high pertussis-incidence and low vaccination coverage in German adults, improvement of pertussis vaccine uptake is vital, e. g. through awareness campaigns targeting both physicians in private practice and hospitals.

Report on the 1st international workshop on procedures for the development of evidence-based vaccination recommendations, Berlin, Germany, 22–23 November 2010 ☆

In November 2010, experts from European and North-American countries met in Berlin, Germany, to discuss improved methods for the development of evidence-based vaccination recommendations. The objectives of the workshop were to (i) review current procedures and experiences of National Immunization Technical Advisory Groups (NITAGs) in developing a framework for evidence-based vaccination recommendations, (ii) discuss the applicability of methods like Grading of Recommendations Assessment, Development and Evaluation (GRADE), and (iii) to identify opportunities for international collaboration to support NITAGs in the development of vaccination recommendations at country-level. Recognizing that a systematic and transparent approach is necessary to promote the quality and acceptance of vaccination recommendations, various decision making frameworks have been implemented by national and international advisory groups addressing common key aspects of knowledge, such as the burden of disease or characteristics of the vaccine. There are several challenges when grading the quality of evidence of some immunization-specific topics (e.g. population-level effects of vaccination). This does not, however, necessitate development of an entirely new systematic methodology. The participants concluded that (i) GRADE or a modification of this methodology is suitable for the grading of quality of evidence related to vaccine effectiveness and safety, and that (ii) international cooperation would be beneficial to develop common framework methodologies for certain aspects of national immunization recommendation developments in order to avoid duplication of efforts, to build on existing strengths, and to support NITAGs worldwide.

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.

Statements of general practitioners on cooperation with specialists and a future health care system

Zusammenfassung.Hintergrund und Ziel:Bei den gesundheitspolitischen Diskussionen um die Neustrukturierung des ambulanten Gesundheitssystems in Deutschland kommt den Hausärzten eine besondere Bedeutung zu. Von Interesse ist, wie das Versorgungsgeschehen von Hausärzten eingeschätzt wird. Ziel der vorliegenden Studie war, Einstellungen von Berliner Hausärzten zu einzelnen Bereichen ihres beruflichen Alltags zu erfassen.Methodik:Mit 14 Hausärztinnen und 16 Hausärzten aus Berlin wurde eine qualitative Befragung durchgeführt. Die 30 niedergelassenen Kollegen wurden u.a. nach ihren Einstellungen bezüglich der Zusammenarbeit mit Spezialisten und den Vorstellungen zukünftiger Versorgungsstrukturen befragt. Die Interviews wurden durch formalisiertes Zusammenfassen, durch Strukturieren und durch Explikation im Sinne der qualitativen Inhaltsanalyse nach Mayring ausgewertet.Ergebnisse: Aus Sicht der Hausärzte wird die ambulante Zusammenarbeit durch Kenntnis des Spezialisten, durch den schnellen telefonischen Kontakt und die Möglichkeit einer kurzfristigen Terminvergabe beim Fachkollegen erleichtert. Eine digitale Vernetzung in regionalen Ärzteverbünden wird als wegweisend für zukünftige ambulante Versorgungsstrukturen betrachtet.Schlussfolgerung:Schnelle patientenbezogene Lösungsstrategien sind für die Entscheidung zur Zusammenarbeit mit Spezialisten von großer Bedeutung. Durch digitale Vernetzungsstrukturen lässt sich die Zusammenarbeit von Hausärzten und Spezialisten zukünftig möglicherweise verbessern.Abstract.Background and Purpose:Ideas of general practitioners (GPs) could be of value for the restructuring of the German ambulant health care system. The way managed care is seen by GPs is of particular interest. The aim of this study was to record opinions of GPs, working in Berlin, in regard to several aspects of their daily work.Methods:14 female and 16 male GPs from Berlin participated in a qualitative survey. These 30 GPs were interviewed about their attitude toward cooperation with specialized colleagues and their opinions on a future medical care sysem. The interviews performed were summarized, structured and analyzed according to the qualitative content analysis by Mayring.Results:From the GPs’ point of view, ambulant cooperation is facilitated by knowing specialized colleagues, by staying in close contact to them via telephone and by being able to arrange short–term appointments with these specialists. A closer cooperation with specialists in a network as well as an advanced use of digital information systems for accessing patients’ data were considered to be vital elements for a future health care system.Conclusion: An important reason for choosing the cooperation with specialists is to find quick comprehensive treatment strategies for patients. It may be concluded that ambulant managed care of patients could be optimized with the creation of medical networks.

Measles outbreak spreading from the community to an anthroposophic school, Berlin, 2011

Between April and July 2011 there was an outbreak of measles virus, genotype D4, in Berlin, Germany. We identified 73 case-patients from the community and among students of an anthroposophic school, who participated in a 4-day school trip, as well as their family and friends. Overall, 27% were aged ≥ 20 years, 57% were female and 15% were hospitalized. Of 39 community case-patients, 38% were aged ≥ 20 years, 67% were female and 63% required hospitalization. Unvaccinated students returning from the school trip were excluded from school, limiting transmission. Within the group of 55 school-trip participants, including 20 measles case-patients, a measles vaccine effectiveness of 97.1% (95% confidence interval 83.4-100) for two doses was estimated using exact Poisson regression. Our findings support school exclusions and the recommendation of one-dose catch-up vaccination for everyone born after 1970 with incomplete or unknown vaccination status, in addition to the two-dose routine childhood immunization recommendation.

Hot Spot: Epidemiologie der Masern und Röteln in Deutschland und Europa

The elimination of measles and rubella by 2015 is an important goal set by the World Health Organization European Region (WHO/Europa). Since 1991, the incidence of measles in WHO/Europa declined owing to routine childhood vaccination and supplementary immunization activities in the region. However, in many countries of Western Europe elimination of measles and rubella remains a challenge, and every year there are outbreaks with partly long-lasting transmission chains and dissemination of the virus internationally. In Germany, outbreaks occur because of the high proportion of susceptible individuals in specific population groups. In 2011, over 1,600 cases were reported (19.7 per 1,000,000 inhabitants, data from the Robert Koch Institute) whereas in 2012 only 167 cases were reported to the Robert Koch Institute (2 per 1,000,000 inhabitants). It is unclear whether the declining trend will continue in the following years due to improved vaccination coverage or whether number of cases will rise again because of the accumulation of susceptible groups. In Germany, there are currently no representative, country-wide data on rubella; however, data from the eastern federal states provide important epidemiological insights. Outbreaks are seldom reported, but statutory notification of rubella and congenital rubella syndrome was implemented in March 2013. As a result, it will be possible to better assess the epidemiology of rubella in Germany, although a considerable underreporting of rubella cases is anticipated.

Hausärztliche Sicht zur Kooperation mit Spezialisten und Visionen zukünftiger Versorgungsstrukturen

Zusammenfassung.Hintergrund und Ziel:Bei den gesundheitspolitischen Diskussionen um die Neustrukturierung des ambulanten Gesundheitssystems in Deutschland kommt den Hausärzten eine besondere Bedeutung zu. Von Interesse ist, wie das Versorgungsgeschehen von Hausärzten eingeschätzt wird. Ziel der vorliegenden Studie war, Einstellungen von Berliner Hausärzten zu einzelnen Bereichen ihres beruflichen Alltags zu erfassen.Methodik:Mit 14 Hausärztinnen und 16 Hausärzten aus Berlin wurde eine qualitative Befragung durchgeführt. Die 30 niedergelassenen Kollegen wurden u.a. nach ihren Einstellungen bezüglich der Zusammenarbeit mit Spezialisten und den Vorstellungen zukünftiger Versorgungsstrukturen befragt. Die Interviews wurden durch formalisiertes Zusammenfassen, durch Strukturieren und durch Explikation im Sinne der qualitativen Inhaltsanalyse nach Mayring ausgewertet.Ergebnisse: Aus Sicht der Hausärzte wird die ambulante Zusammenarbeit durch Kenntnis des Spezialisten, durch den schnellen telefonischen Kontakt und die Möglichkeit einer kurzfristigen Terminvergabe beim Fachkollegen erleichtert. Eine digitale Vernetzung in regionalen Ärzteverbünden wird als wegweisend für zukünftige ambulante Versorgungsstrukturen betrachtet.Schlussfolgerung:Schnelle patientenbezogene Lösungsstrategien sind für die Entscheidung zur Zusammenarbeit mit Spezialisten von großer Bedeutung. Durch digitale Vernetzungsstrukturen lässt sich die Zusammenarbeit von Hausärzten und Spezialisten zukünftig möglicherweise verbessern.Abstract.Background and Purpose:Ideas of general practitioners (GPs) could be of value for the restructuring of the German ambulant health care system. The way managed care is seen by GPs is of particular interest. The aim of this study was to record opinions of GPs, working in Berlin, in regard to several aspects of their daily work.Methods:14 female and 16 male GPs from Berlin participated in a qualitative survey. These 30 GPs were interviewed about their attitude toward cooperation with specialized colleagues and their opinions on a future medical care sysem. The interviews performed were summarized, structured and analyzed according to the qualitative content analysis by Mayring.Results:From the GPs’ point of view, ambulant cooperation is facilitated by knowing specialized colleagues, by staying in close contact to them via telephone and by being able to arrange short–term appointments with these specialists. A closer cooperation with specialists in a network as well as an advanced use of digital information systems for accessing patients’ data were considered to be vital elements for a future health care system.Conclusion: An important reason for choosing the cooperation with specialists is to find quick comprehensive treatment strategies for patients. It may be concluded that ambulant managed care of patients could be optimized with the creation of medical networks.