Walter Biederbick

Dual-Use Research and Technological Diffusion: Reconsidering the Bioterrorism Threat Spectrum

The global security community continues to view a potential bioterrorist event with concern. Kofi Annan, former Secretary General of the United Nations, stated “the most important under-addressed threat relating to terrorism…is that of terrorists using a biological weapon” [1]. The European Commission believes that biological weapons “may have particular attractions for terrorists” [2]. The United States Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism believes it is very likely that a weapon of mass destruction will be used in a terrorist attack by the end of 2013, and that an attack with a biological weapon is more likely than one with a nuclear weapon [3].

Die Auswirkungen des Klimawandels

Increasing temperatures, but also other climatic factors, will have an impact on human health. Apart from the direct consequences of extreme weather conditions (e.g., heat-related fatalities), indirect health consequences in the long-term are also of great importance. In addition to a likely increase in allergic diseases and additional complications in the course of cardiovascular and respiratory diseases, infectious diseases are of particular interest. In Germany, endemic pathogens, such as hantavirus (with its reservoir in small rodents), tick-borne pathogens (Borrelia burgdorferi, tick-borne encephalitis virus), and certain food- and water-borne pathogens, are of concern. Mild winters favor rodent populations and may result in hantavirus epidemics in the subsequent summer period. Statistical analyses show a significant association between temperature and campylobacter incidence in Germany. An outbreak of rodent-borne leptospirosis among strawberry harvesters enhanced by heavy rainfalls illustrates how weather conditions may influence disease occurrence. Pathogens that are non-endemic in Germany but are imported by humans, vectors, and reservoir animals pose an additional risk to the population. Increasing temperatures improve the conditions for establishment of new vectors and for autochthonous transmission of some pathogens (e.g., chikungunya, dengue, West Nile virus, malaria, or leishmaniasis). Climatic and ecologic conditions in Germany currently do not favor autochthonous outbreaks for most of these pathogens. However, if temperatures increase, as expected, such outbreaks will become more likely. Germany should enhance its research in public health activities in the field of climate change and infectious diseases.ZusammenfassungEin Temperaturanstieg, aber auch andere klimatische Faktoren und die Zunahme von extremen Wetterereignissen werden Auswirkungen auf die menschliche Gesundheit haben. Neben den unmittelbaren Folgen von Extremereignissen (etwa Hitzetote) sind langfristig auch die indirekten Folgeerscheinungen von großer Bedeutung. Neben einer wahrscheinlichen Zunahme von Allergien und einer Verschlimmerung bereits bestehender Herz-Kreislauf-Erkrankungen sowie Atemwegserkrankungen stehen die Infektionskrankheiten im Blickpunkt. Dies betrifft in Deutschland endemische Infektionserreger, beispielsweise Hantaviren mit ihrem Reservoir in Nagetieren, oder durch Zecken übertragene Borrelia-burgdorferi-Spezies und FSME-Viren, aber auch durch Lebensmittel und Wasser übertragene Erreger. Milde Winter in Verbindung mit einem klimabedingten reichhaltigeren Nahrungsangebot können zu wachsenden Nagetierpopulationen und nachfolgenden Hantavirus-Epidemien führen. Statistische Analysen zeigen einen deutlichen Zusammenhang zwischen Temperatur und der Häufigkeit Lebensmittel-übertragener Zoonoseerreger (zum Beispiel Campylobacter). Ein Leptospiroseausbruch bei Erdbeerpflückern in Deutschland wurde durch vorausgehende Starkregenfälle begünstigt. Eine besondere Gefahr geht von Erregern aus, die bisher in Deutschland nicht heimisch sind, aber durch erkrankte Menschen, Vektoren und Reservoirtiere verstärkt eingeschleppt werden können. Bei fortschreitender Erwärmung finden sowohl die Vektoren als auch einige Erreger bessere Bedingungen für die autochthone Ausbreitung. Hier sind vor allem die durch Stechmücken übertragenen Krankheiten wie Chikungunya-, West-Nile-, Dengue-Fieber, Malaria und Leishmaniose zu nennen. Unter den derzeitigen klimatischen Verhältnissen sind in Deutschland für die meisten dieser Erreger noch keine autochthonen Erkrankungsfälle zu erwarten. Aufgrund des erwarteten Temperaturanstiegs und verbesserter Brutbedingungen für die Vektoren müssen wir jedoch auch in Deutschland in Zukunft mit Ausbrüchen durch einige dieser Erreger rechnen. Verstärkte Forschungs- und Public-Health-Aktivitäten im Bereich Klimawandel und Infektionskrankheiten sind erforderlich.AbstractIncreasing temperatures, but also other climatic factors, will have an impact on human health. Apart from the direct consequences of extreme weather conditions (e.g., heat-related fatalities), indirect health consequences in the long-term are also of great importance. In addition to a likely increase in allergic diseases and additional complications in the course of cardiovascular and respiratory diseases, infectious diseases are of particular interest. In Germany, endemic pathogens, such as hantavirus (with its reservoir in small rodents), tick-borne pathogens (Borrelia burgdorferi, tick-borne encephalitis virus), and certain food- and water-borne pathogens, are of concern. Mild winters favor rodent populations and may result in hantavirus epidemics in the subsequent summer period. Statistical analyses show a significant association between temperature and campylobacter incidence in Germany. An outbreak of rodent-borne leptospirosis among strawberry harvesters enhanced by heavy rainfalls illustrates how weather conditions may influence disease occurrence. Pathogens that are non-endemic in Germany but are imported by humans, vectors, and reservoir animals pose an additional risk to the population. Increasing temperatures improve the conditions for establishment of new vectors and for autochthonous transmission of some pathogens (e.g., chikungunya, dengue, West Nile virus, malaria, or leishmaniasis). Climatic and ecologic conditions in Germany currently do not favor autochthonous outbreaks for most of these pathogens. However, if temperatures increase, as expected, such outbreaks will become more likely. Germany should enhance its research in public health activities in the field of climate change and infectious diseases.

Climate changes and emerging diseases. What new infectious diseases and health problem can be expected

Increasing temperatures, but also other climatic factors, will have an impact on human health. Apart from the direct consequences of extreme weather conditions (e.g., heat-related fatalities), indirect health consequences in the long-term are also of great importance. In addition to a likely increase in allergic diseases and additional complications in the course of cardiovascular and respiratory diseases, infectious diseases are of particular interest. In Germany, endemic pathogens, such as hantavirus (with its reservoir in small rodents), tick-borne pathogens (Borrelia burgdorferi, tick-borne encephalitis virus), and certain food- and water-borne pathogens, are of concern. Mild winters favor rodent populations and may result in hantavirus epidemics in the subsequent summer period. Statistical analyses show a significant association between temperature and campylobacter incidence in Germany. An outbreak of rodent-borne leptospirosis among strawberry harvesters enhanced by heavy rainfalls illustrates how weather conditions may influence disease occurrence. Pathogens that are non-endemic in Germany but are imported by humans, vectors, and reservoir animals pose an additional risk to the population. Increasing temperatures improve the conditions for establishment of new vectors and for autochthonous transmission of some pathogens (e.g., chikungunya, dengue, West Nile virus, malaria, or leishmaniasis). Climatic and ecologic conditions in Germany currently do not favor autochthonous outbreaks for most of these pathogens. However, if temperatures increase, as expected, such outbreaks will become more likely. Germany should enhance its research in public health activities in the field of climate change and infectious diseases.ZusammenfassungEin Temperaturanstieg, aber auch andere klimatische Faktoren und die Zunahme von extremen Wetterereignissen werden Auswirkungen auf die menschliche Gesundheit haben. Neben den unmittelbaren Folgen von Extremereignissen (etwa Hitzetote) sind langfristig auch die indirekten Folgeerscheinungen von großer Bedeutung. Neben einer wahrscheinlichen Zunahme von Allergien und einer Verschlimmerung bereits bestehender Herz-Kreislauf-Erkrankungen sowie Atemwegserkrankungen stehen die Infektionskrankheiten im Blickpunkt. Dies betrifft in Deutschland endemische Infektionserreger, beispielsweise Hantaviren mit ihrem Reservoir in Nagetieren, oder durch Zecken übertragene Borrelia-burgdorferi-Spezies und FSME-Viren, aber auch durch Lebensmittel und Wasser übertragene Erreger. Milde Winter in Verbindung mit einem klimabedingten reichhaltigeren Nahrungsangebot können zu wachsenden Nagetierpopulationen und nachfolgenden Hantavirus-Epidemien führen. Statistische Analysen zeigen einen deutlichen Zusammenhang zwischen Temperatur und der Häufigkeit Lebensmittel-übertragener Zoonoseerreger (zum Beispiel Campylobacter). Ein Leptospiroseausbruch bei Erdbeerpflückern in Deutschland wurde durch vorausgehende Starkregenfälle begünstigt. Eine besondere Gefahr geht von Erregern aus, die bisher in Deutschland nicht heimisch sind, aber durch erkrankte Menschen, Vektoren und Reservoirtiere verstärkt eingeschleppt werden können. Bei fortschreitender Erwärmung finden sowohl die Vektoren als auch einige Erreger bessere Bedingungen für die autochthone Ausbreitung. Hier sind vor allem die durch Stechmücken übertragenen Krankheiten wie Chikungunya-, West-Nile-, Dengue-Fieber, Malaria und Leishmaniose zu nennen. Unter den derzeitigen klimatischen Verhältnissen sind in Deutschland für die meisten dieser Erreger noch keine autochthonen Erkrankungsfälle zu erwarten. Aufgrund des erwarteten Temperaturanstiegs und verbesserter Brutbedingungen für die Vektoren müssen wir jedoch auch in Deutschland in Zukunft mit Ausbrüchen durch einige dieser Erreger rechnen. Verstärkte Forschungs- und Public-Health-Aktivitäten im Bereich Klimawandel und Infektionskrankheiten sind erforderlich.AbstractIncreasing temperatures, but also other climatic factors, will have an impact on human health. Apart from the direct consequences of extreme weather conditions (e.g., heat-related fatalities), indirect health consequences in the long-term are also of great importance. In addition to a likely increase in allergic diseases and additional complications in the course of cardiovascular and respiratory diseases, infectious diseases are of particular interest. In Germany, endemic pathogens, such as hantavirus (with its reservoir in small rodents), tick-borne pathogens (Borrelia burgdorferi, tick-borne encephalitis virus), and certain food- and water-borne pathogens, are of concern. Mild winters favor rodent populations and may result in hantavirus epidemics in the subsequent summer period. Statistical analyses show a significant association between temperature and campylobacter incidence in Germany. An outbreak of rodent-borne leptospirosis among strawberry harvesters enhanced by heavy rainfalls illustrates how weather conditions may influence disease occurrence. Pathogens that are non-endemic in Germany but are imported by humans, vectors, and reservoir animals pose an additional risk to the population. Increasing temperatures improve the conditions for establishment of new vectors and for autochthonous transmission of some pathogens (e.g., chikungunya, dengue, West Nile virus, malaria, or leishmaniasis). Climatic and ecologic conditions in Germany currently do not favor autochthonous outbreaks for most of these pathogens. However, if temperatures increase, as expected, such outbreaks will become more likely. Germany should enhance its research in public health activities in the field of climate change and infectious diseases.

Continued vigilance – development of an online evaluation tool for assessing preparedness of medical facilities for biological events

Objective: Effective response to biological events necessitates ongoing evaluation of preparedness. This study was a bilateral German–Israeli collaboration aimed at developing an evaluation tool for assessing preparedness of medical facilities for biological events. Methods: Measurable parameters were identified through a literature review for inclusion in the evaluation tool and disseminated to 228 content experts in two modified Delphi cycles. Focus groups were conducted to identify psychosocial needs of the medical teams. Table-top and functional exercises were implemented to review applicability of the tool. Results: One hundred seventeen experts from Germany and Israel participated in the modified Delphi. Out of 188 parameters that were identified, 183 achieved a consensus of >75% of the content experts. Following comments recommended in the Delphi cycles, and feedback from focus groups and hospital exercises, the final tool consisted of 172 parameters. Median level of importance of each parameter was calculated based on ranking recommended in the Delphi process. Computerized web-based software was developed to calculate scores of preparedness for biological events. Conclusion: Ongoing evaluation means, such as the tool developed in the study, can facilitate the need for a valid and reliable mechanism that may be widely adopted and implemented as quality assurance measures. The tool is based on measurable parameters and indicators that can effectively present strengths and weaknesses in managing a response to a public health threat, and accordingly, steps can be implemented to improve readiness. Adoption of such a tool is an important component of assuring public health and effective emergency management.

Aufgaben und Funktion der Ständigen Arbeitsgemeinschaft der Kompetenz- und Behandlungszentren für hochkontagiöse, lebensbedrohliche Erkrankungen

ZusammenfassungDie Einschleppung von Tropenkrankheiten nach Deutschland wird durch den zunehmenden Ferntourismus und durch die Globalisierung wirtschaftlicher Aktivitäten zu einem immer häufiger auftretenden Problem für das Gesundheitswesen. Die vernetzte Struktur landkreis- und teilweise länderübergreifender Kompetenzzentren für hochkontagiöse lebensbedrohliche Infektionskrankheiten hat sich bewährt und gezeigt, dass durch die Verknüpfung von öffentlichem Gesundheitsdienst (ÖGD), klinischer Versorgung, laborgestützte Spezialdiagnostik, Feuerwehr/Rettungsdienst und Krankenhaushygiene auch auf zunächst unerwartete infektiologische Situationen schnell und professionell reagiert werden kann. Mit diesen Netzwerken, die sich in der Ständigen Arbeitsgemeinschaft der Kompetenz- und Behandlungszentren (StAKoB) zusammengeschlossen haben, verfügt Deutschland derzeit über ein weltweit einzigartiges Instrument zur Behandlung hochinfektiöser, lebensbedrohlicher Infektionskrankheiten. Im vorliegenden Beitrag werden die Ziele und die Struktur der StAKoB dargestellt.AbstractThe introduction of tropical diseases into Germany is becoming a more and more frequent public health problem due to increasing long distance travel and the globalization of economic activities. A network of centers of excellence for imported, highly contagious diseases has proven efficient and shown that the linking of public health service, clinical care, laboratory-based special diagnostics, ambulance service, and hospital hygiene can react quickly and professionally in even unexpected situations in clinical infectiology. These networks joined forces in the “Permanent Working Group of the Medical Competence and Treatment Centers“ (Ständigen Arbeitsgemeinschaft der Kompetenz- und Behandlungszentren, StAKoB). Not only in Germany but also worldwide, the StAKoB is a unique system for the treatment of imported highly contagious diseases. The goals and structure of the StAKoB are presented in this article.

Hygiene perception changes during the influenza A H1N1 pandemic in Germany: incorporating the results of two cross-sectional telephone surveys 2008–2009

BackgroundThe federal campaign Wir gegen Viren [Us against viruses] promoted hygiene in Germany during the influenza A H1N1 pandemic in 2009. The intervention aimed to encourage people to protect themselves against respiratory infections by simple means of hygiene behaviour. Quantitative research was carried out to outline changes in hygiene perception of the population over time, and to find out whether the potential hygiene perception changes were consistent to the federal campaign about hygiene or not.MethodsTo determine changes in the hygiene perception of the population, two cross-sectional telephone surveys were held, each one with n = 2006 participants. The initial survey was carried out before the influenza A H1N1 pandemic in calendar week 49–51 in 2008 and the second in week 48 in 2009 directly after the peak of the pandemic in Germany. The questionnaire contained indicators about perceived hand hygiene efficacy, preference for coughing into the sleeve, propensity for presenteeism while showing symptoms of a cold and acceptance of hygiene masks.ResultsThe proportion of people who perceive the efficacy of hand washing as “very good” increased significantly from 50.9% in 2008 to 61.1% in 2009. The proportion of people who perceive coughing into the sleeve as the best way to cough increased even more dramatically from 4.8% in 2008 to 38.3% in 2009. In contrast the propensity for presenteeism decreased significantly: The proportion of people who state that they always report to work while they show symptoms of a cold decreased from 50.8% in 2008 to 40.9% in 2009. Acceptance of hygiene masks has not changed significantly from 2008 to 2009.ConclusionsThe results revealed changes in hygiene perception during influenza A H1N1 pandemic in Germany. The changes we found are in accordance with the hygiene recommendations given by the federal campaign Wir gegen Viren [Us against viruses]. Results can constitute a practical benchmark for future research about hygiene perception and hygiene promotion for adults. A pivotal question is: does the increase in hygiene perception persist after the pandemic has ceased?

Unfinished Business: Efforts to Define Dual-Use Research of Bioterrorism Concern

Biotechnological research poses a special security problem because of the duality between beneficial use and misuse. In order to find a balance between regulating potentially dangerous research and assuring scientific advancement, a number of assessments have tried to define which types of research are especially open to misuse and should therefore be considered dual-use research of special concern requiring rigorous oversight. So far, there has been no common understanding of what such activities are. Here we present a review of 27 assessments focusing on biological dual-use issues published between 1997 and 2008. Dual-use research activities identified by these assessments as being of special concern were compiled and compared. Moreover, from these 27 assessments, the primary research publications explicitly identified as examples of concerning research activities were extracted and analyzed. We extracted a core list of 11 activities of special concern and show that this list does not match with the reasons why primary research publications were identified as being of special concern. Additionally, we note that the 11 activities identified are not easily conducted or replicated, and therefore the likelihood of their being used in a high-tech mass casualty bioterrorism event should be reevaluated.

Mit Wasser und Seife gegen die Grippe

ZusammenfassungPharmazeutische Maßnahmen wie die Impfung und die antivirale Prophylaxe sind nur 2 Bausteine zum Infektionsschutz der Bevölkerung. Ein dritter, entscheidender Baustein sind einfache, nicht-pharmazeutische Maßnahmen wie die Händehygiene. In einer qualitativen Studie wird zunächst ermittelt, wie das Händewaschen aktuell in der Bevölkerung verankert ist. Darauf aufbauend werden 7 Hypothesen formuliert, die Bedarf für weitere Forschung zur Förderung der Händehygiene aufzeigen. Das Potenzial für derartige Forschung liegt beispielsweise in der Konzeption und Evaluation von Informationskampagnen zur Händehygiene. Die 7 Hypothesen lauten: Hypothese 1 Gesundheitstipps haben eine höhere Chance auf Verhaltensänderung, wenn sie dem Rezipienten die persönliche Betroffenheit verständlich und erlebbar machen. Hypothese 2 Hygiene dient hauptsächlich dem Wohlgefühl und der Gesellschaftsfähigkeit. Hypothese 3 Eine emotionale Verbindung zwischen Hygiene und Gesundheit besteht durch das Ekelgefühl. Hypothese 4 Das Händewaschen wird vorwiegend rituell und nach gefühltem Bedarf durchgeführt. Hypothese 5 Der Ansteckungsweg von Grippe/Atemwegsinfektionen ist bisher nur so weit bewusst, wie er beobachtbar ist, also in Bezug auf Husten, Niesen und dabei entstehende Tröpfchen. Hypothese 6 Das Bewusstmachen des Übertragungswegs „Hand“ steigert die Motivation zum Händewaschen. Hypothese 7 In der Pandemie erhöht sich der Informationsbedarf und die Bereitschaft zum persönlichen Infektionsschutz.AbstractMedical interventions like vaccination and antiviral prophylaxis are only two ways of protecting the population from infectious diseases. A third and decisive method is to apply non-pharmaceutical interventions like hand hygiene. A qualitative study identified the role hand washing actually plays in the daily life of the population. Based on the results, seven hypotheses are proposed which point to the need for further research about promotion of hand hygiene, e.g. the conception and evaluation of hand washing advertising campaigns. Hypothesis 1 Health tips are more likely to be followed if they communicate clearly and understandably the personal relevance of the information to the recipients. Hypothesis 2 For many, hygiene serves above all to make them feel good and more comfortable around others. Hypothesis 3 The feeling of disgust is an emotional connection between health and hygiene. Hypothesis 4 People mainly wash their hands ritually and when they actually feel the need to clean their hands. Hypothesis 5 As far as most people are aware, the means of transmission of influenza and other respiratory diseases are only the ones they can observe, namely coughing, sneezing, and the resulting visible droplets. Hypothesis 6 People are more motivated to wash their hands after learning that infections can be spread via the hands. Hypothesis 7 A pandemic situation increases the population’s demand for information and people’s willingness to protect themselves from infection.Medical interventions like vaccination and antiviral prophylaxis are only two ways of protecting the population from infectious diseases. A third and decisive method is to apply non-pharmaceutical interventions like hand hygiene. A qualitative study identified the role hand washing actually plays in the daily life of the population. Based on the results, seven hypotheses are proposed which point to the need for further research about promotion of hand hygiene, e.g. the conception and evaluation of hand washing advertising campaigns. HYPOTHESIS 1: Health tips are more likely to be followed if they communicate clearly and understandably the personal relevance of the information to the recipients. HYPOTHESIS 2: For many, hygiene serves above all to make them feel good and more comfortable around others. HYPOTHESIS 3: The feeling of disgust is an emotional connection between health and hygiene. HYPOTHESIS 4: People mainly wash their hands ritually and when they actually feel the need to clean their hands. HYPOTHESIS 5: As far as most people are aware, the means of transmission of influenza and other respiratory diseases are only the ones they can observe, namely coughing, sneezing, and the resulting visible droplets. HYPOTHESIS 6: People are more motivated to wash their hands after learning that infections can be spread via the hands. HYPOTHESIS 7: A pandemic situation increases the populations demand for information and peoples willingness to protect themselves from infection.

A screening tool to prioritize public health risk associated with accidental or deliberate release of chemicals into the atmosphere

The Chemical Events Working Group of the Global Health Security Initiative has developed a flexible screening tool for chemicals that present a risk when accidentally or deliberately released into the atmosphere. The tool is generic, semi-quantitative, independent of site, situation and scenario, encompasses all chemical hazards (toxicity, flammability and reactivity), and can be easily and quickly implemented by non-subject matter experts using freely available, authoritative information. Public health practitioners and planners can use the screening tool to assist them in directing their activities in each of the five stages of the disaster management cycle.

[Fighting the flu with soap and water. Hand washing as an infection control recommendation to the population--7 hypotheses from a qualitative study about hygiene, flu and pandemic].

ZusammenfassungPharmazeutische Maßnahmen wie die Impfung und die antivirale Prophylaxe sind nur 2 Bausteine zum Infektionsschutz der Bevölkerung. Ein dritter, entscheidender Baustein sind einfache, nicht-pharmazeutische Maßnahmen wie die Händehygiene. In einer qualitativen Studie wird zunächst ermittelt, wie das Händewaschen aktuell in der Bevölkerung verankert ist. Darauf aufbauend werden 7 Hypothesen formuliert, die Bedarf für weitere Forschung zur Förderung der Händehygiene aufzeigen. Das Potenzial für derartige Forschung liegt beispielsweise in der Konzeption und Evaluation von Informationskampagnen zur Händehygiene. Die 7 Hypothesen lauten: Hypothese 1 Gesundheitstipps haben eine höhere Chance auf Verhaltensänderung, wenn sie dem Rezipienten die persönliche Betroffenheit verständlich und erlebbar machen. Hypothese 2 Hygiene dient hauptsächlich dem Wohlgefühl und der Gesellschaftsfähigkeit. Hypothese 3 Eine emotionale Verbindung zwischen Hygiene und Gesundheit besteht durch das Ekelgefühl. Hypothese 4 Das Händewaschen wird vorwiegend rituell und nach gefühltem Bedarf durchgeführt. Hypothese 5 Der Ansteckungsweg von Grippe/Atemwegsinfektionen ist bisher nur so weit bewusst, wie er beobachtbar ist, also in Bezug auf Husten, Niesen und dabei entstehende Tröpfchen. Hypothese 6 Das Bewusstmachen des Übertragungswegs „Hand“ steigert die Motivation zum Händewaschen. Hypothese 7 In der Pandemie erhöht sich der Informationsbedarf und die Bereitschaft zum persönlichen Infektionsschutz.AbstractMedical interventions like vaccination and antiviral prophylaxis are only two ways of protecting the population from infectious diseases. A third and decisive method is to apply non-pharmaceutical interventions like hand hygiene. A qualitative study identified the role hand washing actually plays in the daily life of the population. Based on the results, seven hypotheses are proposed which point to the need for further research about promotion of hand hygiene, e.g. the conception and evaluation of hand washing advertising campaigns. Hypothesis 1 Health tips are more likely to be followed if they communicate clearly and understandably the personal relevance of the information to the recipients. Hypothesis 2 For many, hygiene serves above all to make them feel good and more comfortable around others. Hypothesis 3 The feeling of disgust is an emotional connection between health and hygiene. Hypothesis 4 People mainly wash their hands ritually and when they actually feel the need to clean their hands. Hypothesis 5 As far as most people are aware, the means of transmission of influenza and other respiratory diseases are only the ones they can observe, namely coughing, sneezing, and the resulting visible droplets. Hypothesis 6 People are more motivated to wash their hands after learning that infections can be spread via the hands. Hypothesis 7 A pandemic situation increases the population’s demand for information and people’s willingness to protect themselves from infection.Medical interventions like vaccination and antiviral prophylaxis are only two ways of protecting the population from infectious diseases. A third and decisive method is to apply non-pharmaceutical interventions like hand hygiene. A qualitative study identified the role hand washing actually plays in the daily life of the population. Based on the results, seven hypotheses are proposed which point to the need for further research about promotion of hand hygiene, e.g. the conception and evaluation of hand washing advertising campaigns. HYPOTHESIS 1: Health tips are more likely to be followed if they communicate clearly and understandably the personal relevance of the information to the recipients. HYPOTHESIS 2: For many, hygiene serves above all to make them feel good and more comfortable around others. HYPOTHESIS 3: The feeling of disgust is an emotional connection between health and hygiene. HYPOTHESIS 4: People mainly wash their hands ritually and when they actually feel the need to clean their hands. HYPOTHESIS 5: As far as most people are aware, the means of transmission of influenza and other respiratory diseases are only the ones they can observe, namely coughing, sneezing, and the resulting visible droplets. HYPOTHESIS 6: People are more motivated to wash their hands after learning that infections can be spread via the hands. HYPOTHESIS 7: A pandemic situation increases the populations demand for information and peoples willingness to protect themselves from infection.