Sabine Reiter

The epidemiology of pertussis in Germany: past and present

BackgroundCurrent and past pertussis epidemiology in the two parts of Germany is compared in the context of different histories of vaccination recommendations and coverage to better understand patterns of disease transmission.MethodsAvailable regional pertussis surveillance and vaccination coverage data, supplemented by a literature search for published surveys as well as official national hospital and mortality statistics, were analyzed in the context of respective vaccination recommendations from 1964 onwards.ResultsRoutine childhood pertussis vaccination was recommended in the German Democratic Republic (GDR) from 1964 and in former West German states (FWG) from 1969, but withdrawn from 1974–1991 in FWG. Pertussis incidence declined to <1 case/100.000 inhabitants in GDR prior to reunification in 1991, while in FWG, where pertussis was not notifiable after 1961, incidence was estimated at 160–180 cases/100.000 inhabitants in the 1970s-1980s. Despite recommendations for universal childhood immunization in 1991, vaccination coverage decreased in former East German States (FEG) and increased only slowly in FWG. After introduction of acellular pertussis vaccines in 1995, vaccination coverage increased markedly among younger children, but remains low in adolescents, especially in FWG, despite introduction of a booster vaccination for 9–17 year olds in 2000. Reported pertussis incidence increased in FEG to 39.3 cases/100.000 inhabitants in 2007, with the proportion of adults increasing from 20% in 1995 to 68% in 2007. From 2004–2007, incidence was highest among 5–14 year-old children, with a high proportion fully vaccinated according to official recommendations, which did not include a preschool booster until 2006. Hospital discharge statistics revealed a ~2-fold higher pertussis morbidity among infants in FWG than FEG.ConclusionThe shift in pertussis morbidity to older age groups observed in FEG is similar to reports from other countries with longstanding vaccination programs and suggests that additional booster vaccination may be necessary beyond adolescence. The high proportion of fully vaccinated cases in older children in FEG suggests waning immunity 5–10 years after primary immunisation in infancy. The higher incidence of pertussis hospitalisations in infants suggests a stronger force of infection in FWG than FEG. Nationwide pertussis reporting is required for better evaluation of transmission patterns and vaccination policy in both parts of Germany.

Monitoring pandemic influenza A(H1N1) vaccination coverage in Germany 2009/10 – Results from thirteen consecutive cross-sectional surveys

To monitor pandemic influenza A(H1N1) vaccine uptake during the vaccination campaign in Germany 2009/10, thirteen consecutive cross-sectional telephone-surveys were performed between November 2009 and April 2010. In total 13,010 household-interviews were conducted. Vaccination coverage in persons >14 years of age remained low, both in the general population (8.1%; 95%CI: 7.4-8.8) and in specific target groups such as healthcare workers and individuals with underlying chronic diseases (12.8%; 95%CI: 11.4-14.4). Previous vaccination against seasonal influenza was a main factor independently associated with pandemic influenza vaccination (Odds ratio=8.8; 95%CI: 7.2-10.8). The campaign failed to reach people at risk who were not used to receive their annual seasonal influenza shot.

Cross-sectional study on factors associated with influenza vaccine uptake and pertussis vaccination status among pregnant women in Germany.

Pregnant women and their newborns are at increased risk for influenza-related complications; the latter also have an increased risk for pertussis-related complications. In Germany, seasonal influenza vaccination is recommended for pregnant women since 2010. A dose of pertussis-containing vaccine has been recommended since 2004 for women of childbearing age if they have not been vaccinated within the past 10 years. We conducted a nationwide cross-sectional survey among pregnant women in February/March 2013 to assess knowledge, attitudes, and practices related to influenza vaccination during pregnancy and to identify factors associated with their pertussis vaccination status. In total, 1025 pregnant women participated and provided information through a self-administered questionnaire. Of these, 23.2% were vaccinated against seasonal influenza during the 2012/13 season; 15.9% during their pregnancy. Major reasons for being unvaccinated (n=686 respondents) were lack of confidence in the vaccine (60.4%) and the perception that vaccination was not necessary (40.3%). Influenza vaccination during pregnancy was independently associated with having received influenza vaccine in the previous season, having received a recommendation from a physician, a high level of vaccine-related knowledge and of perceived disease severity. In contrast, knowledge of the recommendation for regular hand-washing to prevent influenza and the perception that vaccine-related side effects were likely to occur or likely to be severe were negatively associated with vaccine uptake. Receipt of a pertussis vaccine in the past 10 years was reported by 22.5% of participants. Pertussis vaccine uptake was independently associated with living in the Eastern federal states and receiving seasonal influenza vaccination annually, while a migration background was associated with a lower uptake. To enhance vaccine uptake in pregnant women and women of childbearing age, special efforts must be undertaken to improve knowledge of both recommendations and the benefits of vaccination. Gynecologists could serve as important facilitators.

Monitoring pandemic influenza A(H1N1) vaccination coverage in Germany 2009/10

To monitor pandemic influenza A(H1N1) vaccine uptake during the vaccination campaign in Germany 2009/10, thirteen consecutive cross-sectional telephone-surveys were performed between November 2009 and April 2010. In total 13,010 household-interviews were conducted. Vaccination coverage in persons >14 years of age remained low, both in the general population (8.1%; 95%CI: 7.4-8.8) and in specific target groups such as healthcare workers and individuals with underlying chronic diseases (12.8%; 95%CI: 11.4-14.4). Previous vaccination against seasonal influenza was a main factor independently associated with pandemic influenza vaccination (Odds ratio=8.8; 95%CI: 7.2-10.8). The campaign failed to reach people at risk who were not used to receive their annual seasonal influenza shot.

Risk perception and information-seeking behaviour during the 2009/10 influenza A(H1N1)pdm09 pandemic in Germany.

During the influenza A(H1N1)pdm09 pandemic in 2009/10, a total of 13 consecutive surveys were carried out of the general population in Germany to monitor knowledge, attitude and behaviour concerning the disease and vaccination against pandemic influenza in real time. In total, 13,010 persons aged 14 years or older were interviewed by computer-assisted telephone techniques between November 2009 and April 2010. During the peak of the pandemic, only 18% of participants stated that they perceived the risk of pandemic influenza as high; this proportion fell to 10% in January 2010. There was a significant difference in information-seeking behaviour among population subgroups concerning the disease and vaccine uptake. However, in all subgroups, conventional media sources such as television, radio and newspapers were more frequently used than the Internet. While the majority of participants (78%) felt sufficiently informed to make a decision for or against vaccination, overall vaccination coverage remained low. Among those who decided against vaccination, fear of adverse events and perception that the available vaccines were not sufficiently evaluated were the most frequently stated reasons. Such mistrust in the vaccines and the perceived low risk of the disease were the main barriers that contributed to the low vaccination coverage in Germany during the pandemic.

Impfgegner und Impfskeptiker

ZusammenfassungImpfkritiker, d. h. Impfgegner und Impfskeptiker, gibt es seit Einführung der Pockenschutzimpfung. Obwohl in Deutschland die Zahl der Impfgegner mit geschätzten 3–5% gering ist, können sie—wie in der Vergangenheit das Beispiel der Pockenschutzimpfung und aktuell die Diskussion zum Kombinationsimpfstoff MMR in England zeigen—doch einen großen Einfluss auf die Impfakzeptanz der Bevölkerung ausüben. Möglichkeiten der modernen Informationsgesellschaft erleichtern die Vernetzung und Verbreitung impfkritischer Ideen. Der Rückgang der impfpräventablen Erkrankungen lässt deren Wahrnehmung in der Öffentlichkeit und Gesundheitspolitik sinken. Auch deshalb werden die sehr seltenen Komplikationen des Impfens im Vergleich zu den bestehenden Erkrankungskomplikationen überbewertet. Vorschläge zum Umgang mit Impfkritikern sollten neben strukturellen Veränderungen in der Impfprävention auch Elemente der Risikokommunikation berücksichtigen.AbstractScepticism and critical attitudes towards immunisation have prevailed since the introduction of the smallpox vaccine. In Germany the anti-vaccine movement is rather small (3–5% of the population). Nevertheless its influence on the acceptance of immunisation by the population may be substantial, as shown by the examples of smallpox vaccination and the recent discussion of the combined MMR vaccine in the UK. Modern societies facilitate networking and the dissemination of anti-vaccination ideas. The decline in the incidence of vaccine-preventable diseases has led to a reduced awareness of possible complications from infectious diseases and to an overestimation of the incidence of rarely occurring adverse events following immunisation. Proposals for managing the anti-vaccine movement must take into account changes in immunisation policies and draw on elements of risk communication.

Progress toward Measles Elimination in Germany

While the former East Germany (FEG) achieved a reduction of measles incidence to <1 case per 100,000 population before reunification in 1990, the former West Germany (FWG) experienced significant measles morbidity. In 2001, according to statutory surveillance data, the incidence of measles was still higher in FWG than in FEG (8.7 vs. 0.7 cases/100,000 population). This article describes the development of the vaccination strategies in FEG and FWG, vaccination coverage, results of seroprevalence studies, measles surveillance in Germany, the epidemiology of a recent outbreak, and the role of laboratory diagnosis for measles control in Germany. Recent establishment of comprehensive nationwide surveillance and prevention programs to attain higher vaccine coverage have led to a decrease in measles incidence. However, further improvement of age-appropriate vaccine coverage and closure of immunity gaps in school-age children are necessary to eliminate measles in Germany.

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.

Prioritization strategies for pandemic influenza vaccine in 27 countries of the European Union and the Global Health Security Action Group: a review

BackgroundAlthough there is rapid progress in vaccine research regarding influenza pandemic vaccines it is expected that pandemic influenza vaccine production can only start once the pandemic virus has been recognized. Therefore, pandemic vaccine capacity will be limited at least during the first phase of an influenza pandemic, requiring vaccine prioritization strategies. WHO recommends developing preliminary priorities for pandemic vaccine use. The goal of this review is to provide a thorough overview of pandemic vaccine prioritization concepts in the 27 European Union (EU) member states and the four non-EU countries of the Global Health Security Action Group.MethodsBetween September and December 2006 data was collected for each country through two data sources: (i) the national influenza pandemic plan; (ii) contacting key persons involved in pandemic planning by email and/or phone and/or faxResultsTwenty-six (84%) countries had established at least one vaccine priority group. Most common reported vaccine priority groups were health care workers (HCW) (100%), essential service providers (ESP) (92%) and high risk individuals (HRI) (92%). Ranking of at least one vaccine priority group was done by 17 (65%) of 26 countries. Fifteen (88%) of these 17 countries including a ranking strategy, decided that HCW with close contact to influenza patients should be vaccinated first; in most countries followed and/or ranked equally by ESP and subsequently HRI. Rationales for prioritization were provided by 22 (85%) of 26 countries that established vaccine priority groups. There was large variation in the phrasing and level of detailed specification of rationales. Seven (32%) of 22 countries providing rationales clearly associated each vaccine priority group with the specific rationale. Ten (32% of the 31 countries studied) countries have consulted and involved ethical experts to guide decisions related to vaccine prioritization.ConclusionIn the majority of the countries the establishment of vaccine priority groups, ranking and underlying rationales are in line with WHO recommendations. In most public plans the criteria by which prioritized groups are identified are not easily recognizable. Clarity however, may be necessary to assure public acceptability of the prioritization. Ethical experts, results of modelling exercises could play an increasing role in the future decision making process.

Ausgewählte Daten zum Impf- und Immunstatus in Deutschland

ZusammenfassungZur Erhöhung der Impfakzeptanz und zur Steigerung der Durchimpfung sind aktuelle Kenntnisse zum Impf- und Immunstatus der Bevölkerung notwendig. Diese Daten stehen in der Bundesrepublik Deutschland bisher nur in unzureichendem Maß zur Verfügung. In Deutschland existiert eine Reihe von Datenquellen zur Ermittlung des Impf- und Immunitätsstatus der Bevölkerung. Die vorhandenen Datenquellen erlauben jedoch nur Schätzungen oder werden wie die repräsentativen Daten aus den Schuleingangsuntersuchungen zu einem sehr späten Zeitpunkt erhoben. Die vorhandenen Daten deuten darauf hin, dass trotz steigender Impfraten in den letzten Jahren noch deutliche Impfdefizite bei einzelnen Impfungen im Kindes- und Jugendalter bestehen und die empfohlenen Impfungen im Erwachsenenalter nur unzureichend wahrgenommen werden. Eine verbesserte Surveillance des Impf- und Immunstatus kann einen wichtigen Beitrag zur gezielten Impflückenschließung leisten.AbstractUp-to-date information on vaccination coverage and seroprevalence are the basis for enhancing the acceptance of vaccination and increasing vaccination coverage. In Germany these data are currently only available to a limited extent. Existent data sources only permit estimates of vaccination coverage or are not age appropriate, such as the representative data from the school entry examinations. Despite increasing vaccination coverage of children and adolescents in recent years, existent data indicate important coverage gaps for certain vaccines. In addition, the vaccination status in adults is often incomplete. Improved surveillance of vaccination coverage and seroprevalence could make an important contribution to closing gaps in vaccination coverage.