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Case definitions ensure standardised criteria for the surveillance of infectious diseases in Germany. Since its last revision in 2007, an update of the complete case definition edition became necessary due to new scientific insights, changes in legislature, terminology and classification systems. At the same time, the case definition should be further standardised and work at local public health authorities should be simplified. The department for infectious disease epidemiology at the Robert Koch Institute (RKI) coordinated the revision of the case definitions. During several feedback sessions, internal RKI experts and external experts from different levels of the German public health system, as well as from medical associations and laboratories, were involved in the revision process. The new edition and an annotated version are published on the RKI website (www.rki.de/falldefinitionen). The new case definitions will become effective on 1st January 2015. The most important changes are summarised in this article.

In the German Reich, smallpox vaccinations were organized by the state. A mandatory vaccination throughout the empire was introduced in 1874, which was continued in the Federal Republic of Germany (FRG) and the German Democratic Republic (GDR) until 1982/1983. From 1935, health departments were responsible for vaccinations. In the GDR, immunization was tightly organized: The state made great efforts to achieve high vaccination rates. Responsibilities were clearly defined at all levels and for all ages. While vaccination was initially mandatory only at the regional level, the legally mandated immunization schedule later contained compulsory vaccinations, e.g., against measles. In the beginning there were mandatory vaccinations in the FRG at the Länder level. Since 1961, the Federal Epidemics Act has impeded obligatory vaccinations. Instead, voluntary vaccinations based on recommendations were stressed. Since the 1980s, vaccinations have been shifted from the public health service sector to office-based physicians. Today, public health authorities offer mainly supplementary vaccinations. In 2007, protective immunizations were introduced as compulsory benefits of the statutory health insurance (SHI). Recently, the German federal states developed a National Vaccination Plan to support immunization strategies.

Rare infectious diseases are of great importance in Germany: Some of them require special measures and precautions to prevent spreading (e.g. virus caused hemorrhagic fevers). For others, e.g. infectious diseases that can be prevented by vaccination, the prevention aspects are important. Summarizing descriptions for several rare diseases which together describe the situation in Germany are only possible on the basis of the notification requirements. The legal obligation for notification represents a good prerequisite to register diseases occurring in Germany. With the introduction of the Protection against Infection Act in 2001 the quality of the available data was improved by using case definitions. The evaluation of existing information indicates: On the basis of the available data there is no evidence that in the foreseeable future a noticeable increase of isolated rare diseases could pose a threat in Germany.

From 1993 to 2007, a total of 11,605 malaria cases were reported to the Robert Koch-Institut. For 9 593 of these cases information on the possible country of infection is available. Analysis of the data indicates that the malaria cases were imported to Germany from 96 countries. The majority of the malaria cases were acquired in Africa, followed by distinctly fewer cases from Asian countries. More than half of all cases were imported from only 6 countries (Ghana, Kenya, Nigeria, Cameroon, Gambia, and India). The number of cases imported from, e.g., Kenya and India has declined, whereas infections from Ghana, Nigeria, and Cameroon have increased during the last years. For more than two-thirds of all infections the predominant parasite species was P. falciparum; this is consistent with the predominance of the African continent as the main source of infection.

Background and Objective: In Germany, malaria is a major imported disease. The national surveillance data from 1993 to 2003 were analysed to assess epidemiologic trends in imported malaria., Methods: Malaria is a notifiable disease in Germany. Laboratory and epidemiologic data are obtained for each malaria case in a standardised way and reported to the Robert Koch-Institut where the central database exists for statistical analysis., Results: From 1993 to 2003, a total of 9148 malaria cases were reported to the Robert Koch-Institut. The annual cases ranged from 598 (1993) to 1045 (2001). No clear trend over the years was observed. The proportion of malaria cases of German origin declined significantly over the years to 50 % in 2003. The proportion of cases aged 40 to 49 years increased over time. However, in each year the highest malaria incidence was found in the age group 20 to 39 years. Case fatality decreased substantially in recent years. In about 25 % of patients malaria diagnosis and treatment start were delayed. This is of great concern since 70 to 80 % of all cases were caused by Plasmodium falciparum. In recent years atovaquone + proguanil as well as arthemether + lumefantrin were increasingly used for treatment (both combination therapies made up for 35 % of treatments in 2003)., Conclusions: Further improvements in counselling and adequate use of malaria prophylaxis in travelers and in timely malaria diagnosis and treatment are necessary.

In Germany, malaria is one of the most frequently imported infectious diseases. In January 2001, the newly implemented Infektionsschutzgesetz (Law for Protection Against Infectious Diseases) brought some important changes in surveillance case notification procedures. After one year, experience shows that the changes did not affect the continuity and representative nature of malaria reporting in Germany. In the years 2000 and 2001, 836 and 1,040 malaria cases, respectively, were reported. In both years, most of the patients were between 30 and 49 years old. 82 % of the infections had been acquired in Africa, and 11 % in Asia. The predominant parasite species was P. falciparum (70 %), followed by P. vivax (12 % in 2000, and 16 % in 2001, respectively). The majority of infections occurred among tourists, fewer in immigrants or business travellers. About two thirds of all patients had not taken any chemoprophylactics. Compared to previous years a decrease in the number of fatal cases was observed (1998: 21, 1999: 18, 2000: 8, 2001: 8). To ameliorate the situation of imported malaria intensified prevention activities are necessary, including efforts to improve choice and compliance of chemoprophylaxis and to facilitate timely diagnosis and treatment.

The number of cases of typhoid fever has decreased in recent years in Germany. In 2000 77 cases were reported (in 1999:111). Most of the cases (84%) were imported from abroad. Travellers can contract the infection when travelling under conditions of poor hygiene in endemic regions. The risk of contracting typhoid fever is high on the Indian subcontinent. Adequate prophylactic measures are the only way to reduce the importation of typhoid fever to Germany.

Malaria is a common imported infectious disease in Germany. A total of 931 cases of malaria were reported in Germany in 1999 (1998: 1,008 cases). Most of the infected patients were 24-45 years of age. Eighty per cent of the cases acquired infection in Africa, in Asia (8.5%) and in Central and South America (5%). Plasmodium falciparum accounted for the largest number of cases (80%) followed by Plasmodium vivax (12%). In 1999 60% of all malaria cases were Germans. Most of them travelled for holidays or study purposes. 20 deaths, all attributed to falciparum malaria, were notified in 1999, most of them (19) were German citizens. In 1999 61% of the patients had not taken chemoprophylaxis at all while travelling abroad. Improving prophylactic measures is the only way to reduce the incidence of malaria cases in Germany.

Worldwide incidence of malaria has increased. This may result in an increasing risk for tourists in different areas of the world. Malaria is an important travellers' disease in Germany. Most cases imported to Germany originated from Africa (77%). Plasmodium falciparum caused 67% of all malaria cases. 63% of all cases were Germans, 76% of whom travelled for holidays or study trips. From 1993 to 1996 89 people died from malaria in Germany. Most cases of fatal malaria were reported among German citizens. The case fatality rate increases with age. About 50% of all patients had not undergone sufficient prophylaxis against malaria. Only 22% of the patients who started prophylactic treatment took chemoprophylactics regularly while travelling abroad. Adequate prophylaxis against malaria is the only way to reduce the incidence of imported cases of malaria.

Adequate prophylaxis should always be the order of the day if anyone plans to visit a foreign country where he may be at risk of being exposed to infectious diseases. Numerous protective vaccinations are available for this purpose in Germany. Basing on the incidence of recorded damage caused by such vaccinations 1971-1990 we must conclude that the risk of damage to health as a result of such vaccinations is very remote. Hence, the protective vaccinations carried out in Germany are of vital importance in respect of keeping down the number of infections.

Hospital-acquired infections are a worldwide problem especially in hospitals for the treatment of acute cases. These infections are among the leading causes of death. Certificates of death of 4656 patients who died in hospitals were analysed. Of these, 564 deaths were caused by nosocomial infections (12.1%). It was estimated that annually around 40,000 deaths in the Federal Republic of Germany are attributable to infections acquired in the hospital.

Malaria was in 1989/90 the most important imported disease in Germany. Most of all cases were imported by German tourists (about 75%). Africa was the most prominently represented geographic region (about 75%). Kenia and Ghana represented there the biggest share. About 33% of all patients had not done a sufficient prophylaxis against malaria. An adequate prophylaxis against malaria taking into consideration the recommendations for medicaments for different geographical areas is imperative before the number of importations of malaria into Germany can be reduced.

73 cases of leprosy were imported into the Federal Republic of Germany between 1981 and 1992. A large number of imported cases came from Asian countries (32 cases). 61 patients were male, 12 female. 30 patients had the tuberculoid type of leprosy, 29 the lepromatous. From the total of 73 leprosy patients 7 were German nationals. Early diagnosis and efficient treatment play an important role in ensuring a good prognosis.

The results of an inquiry about the personnel and organisation of the hospital hygiene in 657 German rehabilitation centres and psychiatric hospitals demonstrate that 24% of these hospitals have a hospital epidemiologist, 44% have infection control nurses and 74% infection control physicians. Infection control committees are present in 64% of these hospitals. 78% of the hospitals use the guideline of the Federal Public Health Office "On the Identification, Prevention and Control of Hospital Infections" as a basis for all decisions on hospital hygiene.

Analysis of the outbreaks of food-borne infections and intoxications with a total of 2,610 patients in 1991 demonstrates that these cases were caused in 67.4% by Salmonella species. Eggs were mainly responsible for the outbreaks, whereas poor kitchen hygiene played also a main part in promoting disease.

Malaria continues to be an important travellers' disease in Germany. In 1988 885 cases of malaria were imported into the Federal Republic of Germany. German tourists to far-away countries represented the biggest share (about 80%). Africa was the most prominently represented continent with 76%. Differentiation according to species of pathogens showed that 68% of the diseases were caused by Plasmodium falciparum. 11 patients died of malaria in 1988, in all cases due to P. falciparum infection. The mortality of the patients increases with age. Only in 5 of 11 persons who died there had been a sufficient prophylaxis against malaria, at least as far as the anamnesis revealed. Careful planning of sufficient prophylaxis taking into consideration the partly very marked resistance to a multitude of drugs, as well as competent medical advice to would-be travellers, are imperative before the number of malaria imports into Germany can be reduced.

The results of an inquiry about the hospital hygiene in 2034 German hospitals demonstrate, that 35% of all hospitals have a hospital epidemiologist, 66% have infection control nurses and 86% infection control physicians. Infection control committees are present in 81% of German hospitals. 88% of all hospitals use the guideline of the Federal Public Health Office "On the Identification, Prevention and Control of Hospital Infections" as a basis for all decisions on hospital hygiene.