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ZusammenfassungDie Leptospirose ist eine Zoonose, die bei Mensch und Tier eine große Bandbreite von Krankheitssymptomen mit sehr milden bis hin zu sehr schweren Verläufen aufweisen kann. In Deutschland ist der Labornachweis einer akuten Infektion meldepflichtig: beim Menschen gemäß Infektionsschutzgesetz und bei Schweinen und Schafen gemäß der Verordnung über meldepflichtige Tierkrankheiten. Die Übertragung erfolgt über direkten und indirekten Kontakt mit dem Urin infizierter Tiere, wobei Nagetiere als Hauptreservoir gelten. Mit einer durchschnittlichen jährlichen Inzidenz von 0,1 gemeldeten Fällen pro 100.000 Einwohner ist die Leptospirose in Deutschland eine seltene Erkrankung.Im Rahmen des vom Bundesministerium für Bildung und Forschung (BMBF) geförderten Projekts „Verbesserung der Öffentlichen Gesundheit durch ein besseres Verständnis der Epidemiologie nagetierübertragener Krankheiten“ (RoBoPub) werden in diesem Übersichtsartikel aktuelle Kenntnisse zur Leptospirose in Deutschland dargestellt. In einem One-Health-Ansatz werden Informationen zum klinischen Bild, verfügbare Prävalenzdaten bei Mensch und Tier und Erkenntnisse über die Erregerverbreitung, die Wirtsassoziation, die Übertragung des Erregers sowie die Umweltstabilität zusammengefasst. Darüber hinaus werden erste Erkenntnisse zum Einfluss von Populationsschwankungen in Nagetierpopulationen auf das Auftreten der Leptospirose diskutiert. Ziel des Übersichtsartikels ist es, die Wahrnehmung für diese gegenwärtig noch vernachlässigte Erkrankung in Deutschland zu erhöhen.In Zukunft sollten auch die im Zuge des Klimawandels möglicherweise vermehrt auftretenden erhöhten Temperaturen und starken Regenfälle und die damit einhergehende häufigere Exposition des Menschen mit den Erregern berücksichtigt werden.

Um Hemmnisse im Zugang zur Gesundheitsversorgung fur Migrierte ohne Papiere abzubauen, hat der niedersachsische Landtag 2014 ein dreijahriges Modellprojekt beschlossen. Hierfur wurden Vergabestellen (VS) in Hannover und Gottingen eingerichtet, wo Migrierte ohne Papiere einen Behandlungsschein (BS) zur Gesundheitsversorgung bei akuten Erkrankungen, Schmerzzustanden, fur Vorsorgeuntersuchungen und fur Impfungen erhalten. Wir untersuchten, welche medizinischen Leistungen wahrend der ersten zwei Jahre des Projektes in Anspruch genommen wurden, um Bedarfe zu identifizieren und Verbesserungsvorschlage zu adressieren. Wir analysierten die Daten der VS der ersten zwei Jahre seit Beginn der BS-Ausgabe (01.02.2016–31.01.2018). Wir werteten demografische Merkmale der Ratsuchenden, Beratungsanlasse, Diagnosen und arztliche Masnahmen deskriptiv aus. Zudem fuhrten wir eine explorative Befragung Ratsuchender bei einer VS zum Thema Impfungen durch (02–05/2018). An 236 Personen wurden 698 BS ausgegeben. Monatlich wurden im Mittel zunachst 17 (02–07/2016), zuletzt 44 Scheine (08/2017–01/2018) ausgegeben. 56 % der Ratsuchenden waren weiblich, 16 % waren

Following a school ski-trip to Austria from 10 to 18/02/2017, nine of 25 participants of the group from Lower Saxony (Germany) developed gastroenteritis. The students and teachers (17–41 years) shared meals in a hotel. Active case finding revealed further cases among German school groups from North Rhine-Westphalia and Schleswig-Holstein, staying at the same hotel in February 2017. We conducted two retrospective cohort studies using self-administered questionnaires on clinical symptoms and food consumption. We defined a case as a trip participant in February 2017, staying at the aforementioned hotel and developing diarrhoea, vomiting or abdominal pain during or within ten days after the trip and/or who had a stool sample tested positive for STEC within four weeks after the trip. During the outbreak investigation, Austrian authorities detected that unlabeled raw cow milk delivered by a dairy farm had been offered at the hotel for breakfast during January and February 2017. Stool samples of participants, samples of milk served in the hotel and fecal samples of various animals kept at the milk-delivering farm were examined by culture and polymerase chain reaction. STEC isolates were typed using Pulsed-field Gel Electrophoresis (PFGE) and Whole-Genome Sequencing (WGS). All 25 participants from Lower Saxony completed the questionnaire on symptoms and milk consumption; 14 were cases (56%). Thirteen of 20 participants who had consumed cold milk fell ill (risk ratio (RR): 3.25; 95%-confidence interval (CI): 0.55–19.32). Of 159 trip participants from North Rhine-Westphalia, 81 completed the questionnaire (51%), 25 were cases (31%); RR for cold milk was 2.11 (CI: 0.89–5.03). The combined RR for cold milk in both groups was 2.49 (CI: 1.16–5.35). Shiga toxin 1a-gene and eaeA-gene positive STEC O103:H2 were detected in nine of 32 patients’ stool samples and in two of 18 dairy farm cattle. Nine isolates from human stool samples and two isolates from cattle fecal samples yielded the same strain with an almost identical PFGE-pattern and WGS-profile. Microbiological and epidemiological evidence identified raw cow milk as the vehicle. Results may have been compromised by misclassification of cases due to a recall bias and mild symptoms. As a result of this outbreak investigation, the Austrian authorities enforced Austrian law in the hotel, to provide milk only when pasteurized. We recommend re-emphasizing the risk of raw milk consumption to providers.

SUMMARYChildren may be at higher risk for carriage of antimicrobial-resistant bacteria because of higher usage of antimicrobials. They also have higher rates of Shiga toxin-producingEscherichia coli(STEC) infections than other population groups. Some infections, particularly in children, are asymptomatic, but still lead to the excretion of large numbers of bacteria and viruses that may cause clinical disease in other individuals. That is one reason why, in Lower Saxony as in other German federal states – asymptomatic carriers of STEC are excluded from nurseries and schools until three consecutive stool samples test negative in order to prevent secondary cases. The prevalence of children who are asymptomatic STEC carriers is unknown. But if it is high, this measure would have substantial socioeconomic effects on families. Infections with extended-spectrumβ-lactamase-producing Enterobacteriaceae (ESBL-E) are an increasing problem for public health, especially for hospitals. However, there are no reliable estimates of the prevalence of asymptomatic ESBL-E carriers in Lower Saxony, as there is no mandatory requirement to report these carriers. In order to discuss the exclusion policies for children attending nurseries and ascertain a baseline of ESBL-E carriers, we conducted a cross-sectional study. The aim was to determine the prevalence of ESBL-E and STEC and identify risk factors for carriage in nursery children without diarrhoea (asymptomatic) aged 0–6 years in four selected districts in Northern Germany. During April–September 2014, we collected stool specimens with the support of voluntarily participating nurseries. We tested for STEC by PCR and for ESBL-E on chromogenic agar. Questionnaires answered by parents contained data on eating and drinking habits, outdoor activities, prior antibiotic treatment and animal contact for each participating child. We compared the epidemiological characteristics of ESBL-E carriersvs.non-carriers by using univariable analysis (Pvalue, odds ratio and 95% confidence interval). We could not perform a statistical analysis for STEC carriers due to the low numbers of positive STEC specimens. Of 224 asymptomatic nursery children, we found a prevalence of 2·3% for ESBL-E carriage and 0·5% for STEC carriage. Asymptomatic ESBL-E carriers were more likely to have consumed raw milk, have had contact with pet rodents, or to have taken antibiotics during the preceding 6 months. We also found a high proportion of raw milk consumption (11%). We suggest that the low STEC prevalence in asymptomatic children supports the current practice of excluding STEC carriers from nurseries. The association between ESBL-E carriage and raw milk consumption and contact with pet rodents needs further investigation.

Transmission of acute respiratory infections (ARI) and acute gastroenteritis (AGE) often occurs in households. The aim of this study was to assess which proportion of ARI and AGE is introduced and transmitted by children in German households with children attending child care. We recruited families with children aged 0–6 years in Braunschweig (Germany), for a 4 months prospective cohort study in the winter period 2014/2015. Every household member was included in a health diary and used nasal swabs for pathogen identification in case of ARI. We defined a transmission if two persons had overlapping periods with symptoms and used additional definitions for sensitivity analyses. In total, 77 households participated with 282 persons. We observed 277 transmission events for ARI and 23 for AGE. In most cases, the first infected person in a household was a child (ARI: 63%, AGE: 53%), and the risk of within-household transmission was two times higher when the index case was a child. In 26 ARI-transmission events, pathogens were detected for both cases; hereof in 35% (95% confidence interval (17–56%)) the pathogens were different. Thus, symptomatic infections in household members, apparently linked in time, were in 2/3 associated with the same pathogens.

SUMMARYInfluenza vaccine effectiveness (VE) has to be estimated anew for every season to explore vaccines’ protective effect in the population. We report VE estimates against laboratory-confirmed influenza A(H1N1)pdm09, A(H3N2) and influenza B among children aged 2–17 years, using test-negative design. Pooled data from two German federal states’ surveillance systems for acute respiratory illness from week 40/2012 to 20/2016 was used, yielding a total of 10 627 specimens. Odds ratios and 95% confidence intervals (95% CIs) for the association between laboratory-confirmed influenza and vaccination status were calculated by multivariate logistic regression adjusting for age, sex, illness onset and federal state. VE was estimated as 1-Odds Ratio. Overall adjusted VE was 33% (95% CI: 24·3–40·7). A strong variation of VE between the seasons and subtypes was observed: highest season- and subtype-specific VE of 86·2% (95% CI: 41·3–96·7) was found against A(H1N1)pdm09 in 7–17-year-olds in 2015/16. Low estimates of VE were observed against A(H3N2) in any season, e.g. 1·5% (95% CI: −39·3–30·3) in 2014/15. Estimates showed a tendency to higher VE among 7–17-year-old children, but differences were not statistically significant. Although our findings are common in studies estimating influenza VE, we discussed several explanations for observed low VE.

In September 2010, an outbreak of acute hepatitis B virus (HBV) infections in a nursing home was notified to public health authorities in Northern Germany. To identify the route of transmission and prevent further cases a retrospective cohort study was conducted. Blood samples of residents were tested for serologic markers of HBV infection and HBV subgenotypes and sequences were analyzed. Outbreak-related cases were defined as residents of the nursing home with detection of hepatitis B surface antigen (HBsAg) and the HBV DNA sequence of the outbreak strain in 2010. Information on possible risk factors as patient care, invasive diagnostic, and therapeutical procedures was collected using a standardized questionnaire. Risk ratios (RR) and 95% confidence intervals (CI) were estimated with exact Poisson regression and binomial regression. Sixty-four residents were included in the study, 5 of them were outbreak-related cases, 12 had a past HBV infection. The outbreak strain belonged to HBV genotype D2 (HBsAg subtype ayw3, Ala118) which is not prevalent in Germany but in Eastern Europe. All cases (median age 81) were female, had diabetes, blood glucose monitoring, and chiropody. In multivariable analysis only blood glucose monitoring was associated with HBV infection (RR = 22, 95%CI 3.0-∞). Blood glucose monitoring was reported to be done by nursing home staff with patient-based reusable lancet devices. In nursing home settings the use of single use lancets for blood glucose monitoring is recommended strongly to prevent transmission. National guidelines on the handling of point-of-care devices and reusable equipment in long-term care facilities should be developed.

Objectives To identify spatial disparities in dental caries experience (measured by dmft (decayed missing filled teeth) index) of children in the city of Braunschweig and to evaluate whether these disparities can be explained by sociodemographic characteristics. Methods We examined the dental health of children aged 3-6 years visiting a daycare centre (DCC) in the metropolitan area of Braunschweig between 2009 and 2014 by combining data on dental health from the annual visits of the local health service with aggregated data on sociodemographic factors for Braunschweig's city districts. We assessed longitudinal patterns of change in average dmft index at district level from 2009 to 2014 using a finite mixture model. We analysed spatial autocorrelation of the district's average dmft indices by Moran's I to identify spatial clusters. With a spatial lag model, we evaluated whether sociodemographic risk factors (data from 2012) were associated with high dmft scores (data from 2014) and whether spatial disparities remained after adjusting for these sociodemographic characteristics. Results The average dmft index decreased slightly (β=−0.048; P

With the intention to deepen the knowledge of the vertical transmission of particular subtypes of Salmonella enterica from “the stable to the table” a case1–case2 analysis in Lower Saxony, Germany, was conducted. The data collection was based on standardised telephone interviews with 1741 Salmonella case persons. Single-factor-analyses revealed statistically significant associations between S. Typhimurium infections and animal keeping (odds ratio (OR): 1.4; 95%-Confidence-interval (CI): 1.2–1.7), especially rodents (OR 1.5; CI 1.2–2.1), and with consumption of meat (OR 1.9; CI 1.3–2.8), raw ground pork (OR 3.0; CI 2.1–4.2) and uncooked pork sausage (OR 2.1; CI 1.6–2.9). The S. Typhimurium phage type DT 104 was associated most with consumption of uncooked pork sausage (OR 3.6; CI 1.3–8.5). Multiple logistic regression analyses confirmed the associations between S. Typhimurium infection and consumption of raw ground pork and with animal contact. The results circumstantiate the assumption of raw pork products still being a relevant source for S. Typhimurium infections in Germany. Therefore, it is recommended to intensify efforts to reduce salmonella infections caused by raw pork products. S. Enteritidis infection was associated statistically significantly with travelling abroad (OR 2.1; CI 1.6–3.3), consumption of raw tomatoes (OR 1.8; CI 1.5–2.1), dried herbs (OR 2.1; CI 1.0–1.8), and undercooked eggs (OR 1.3; CI 1.1–1.6) compared with other serovars. These results were confirmed in multiple logistic regression analyses, as well.

In May 2011 one of the worldwide largest outbreaks of haemolytic uraemic syndrome (HUS) and bloody diarrhoea caused by Shiga toxin-producing Escherichia coli (STEC) serotype O104:H4 occurred in Germany. One of the most affected federal states was Lower Saxony. We present the investigation of a cluster of STEC and HUS cases within this outbreak by means of a retrospective cohort study. After a 70th birthday celebration which took place on 7th of May 2011 among 72 attendants seven confirmed cases and four probable cases were identified, two of them developed HUS. Median incubation period was 10 days. Only 35 persons (48.6%) definitely answered the question whether they had eaten the sprouts that were used for garnishing the salad. Univariable analysis revealed different food items, depending on the case definition, with Odds Ratio (OR)>1 indicating an association with STEC infection, but multivariable logistic regression showed no increased risk for STEC infection for any food item and any case definition. Sprouts as the source for the infection had to be assumed based on the results of a tracing back of the delivery ways from the catering company to the sprouts producer who was finally identified as the source of the entire German outbreak. In this large outbreak several case-control studies failed to identify the source of infection.

Kartographische Darstellungen stellen ein wichtiges Instrument zur Untersuchung der Verteilung von Infektionskrankheiten dar. Sie kommen sowohl zur Analyse raumlicher Zusammenhange, zur Erkennung regionaler Risikofaktoren wie auch zur Kommunikation von Sachverhalten und Analyseergebnissen zum Einsatz. Geoinformationssysteme (GIS), raumliche Analyseverfahren, Modellierungs- und Animationstechniken sowie interaktive kartenbasierte Informationssysteme gehoren heute zum Werkzeug von Epidemiologen.

SUMMARYIn order to identify and assess recent risk factors for sporadic human infections with Salmonella enterica, we conducted a case-control study in Lower Saxony, Germany. The data collection was based on standardized telephone interviews with 1017 cases and 346 controls aged >14 years. Odds ratios were calculated in single-factor and multi-factor analyses for Salmonella cases and two different control groups, i.e. population controls and controls with rotavirus infection. Multi-factor analysis revealed associations between sporadic Salmonella infections for two exposures by both sets of controls: consumption of raw ground pork [adjusted odds ratio (aOR) 2·38, 95% confidence interval (CI) 1·27–4·44] and foreign travel (aOR 2·12, 95% CI 1·00–4·52). Other exposures included consumption of food items containing eggs (aOR 1·43, 95% CI 0·80–2·54), consumption of chicken meat (aOR 1·77, 95% CI 1·26–2·50), outdoor meals/barbecues (aOR 3·96, 95% CI 1·41–11·12) and taking gastric acidity inhibitors (aOR 2·42, 95% CI 1·19–4·92), all were significantly associated with respect to one of the two control groups. The impact of consuming food items containing eggs or chicken meat was lower than expected from the literature. This might be a consequence of Salmonella control programmes as well as increased public awareness of eggs and chicken products being a risk factor for salmonellosis. Efforts to reduce Salmonella infections due to raw pork products should be intensified.

Das Thema „Antibiotika-Resistenz“ ist derzeit eine der wichtigsten infektiologischen Herausforderungen weltweit. Das Niedersachsische Landesgesundheitsamt hat mit ARMIN (Antibiotika-Resistenz-Monitoring in Niedersachsen) ein Sentinel-System etabliert, um regionale Trends im stationaren und ambulanten Bereich in Niedersachsen aufzuzeigen. Derzeit sind 9 Labore daran beteiligt und stellen Einzelfalldaten ihrer routinemasigen mikrobiologischen Untersuchungen bereit. Die Daten werden im Internet mit einer interaktiven Abfrage zur Verfugung gestellt. Von 2006 bis 2010 haben die teilnehmenden Labore rund 800 000 Erregernachweise mitgeteilt. Der Anteil von MRSA (Methicillin-resistenter Staphylococcus aureus ) an allen Staphylococcus aureus stieg von 19,5% im Jahr 2006 auf 23,4% im Jahr 2010 im stationaren Bereich in Niedersachsen. Im gleichen Zeitraum stieg die Resistenz von Escherichia coli gegenuber Cefotaxim von 3,0% auf 8,8%. Die Resistenz von Enterococcus faecium gegenuber Vancomycin sank von 13,6% auf 5,6%. Der Schwerpunkt von ARMIN liegt derzeit auf der Darstellung von Trends und auf der Information der verordnenden Arzte. Zur Standardisierung wurde ein Qualitatszirkel etabliert.

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.

Die Lander haben im Rahmen ihrer gemeinsamen Pandemieplanung mit dem Bund Vorbereitungen fur ein pandemisches Geschehen getroffen. Dazu gehorten das Beschreiben von Verfahrensablaufen unter anderem zu infektionshygienischen Masnahmen in den Pandemieplanen sowie die Bevorratung antiviraler Arzneimittel und Vertragsabschlusse mit Impfstoffherstellern zur Sicherstellung der Versorgung mit Impfstoffen im Pandemiefall. Die gegenuber den Planungsgrundlagen veranderte Situation in der Influenza (H1N1) 2009-Pandemie erforderte zahlreiche kurzfristige Anpassungen und verdeutlichte die Notwendigkeit, die Pandemieplanung zukunftig flexibler zu gestalten. Trotz vieler Hurden, die wahrend des Geschehens zu uberwinden waren, ist es gelungen, ein bundesweit weitgehend abgestimmtes Vorgehen zu erreichen und die Impfstoffverfugbarkeit fur Deutschland sicherzustellen. Im Verlauf der Pandemie offenbarten sich Schwachpunkte der Surveillance, aus denen sich Verbesserungsansatze ableiten liesen. Ein zentraler Punkt fur zukunftige pandemische Geschehen ist die erfolgreiche Kommunikation mit allen Beteiligten, speziell mit der Arzteschaft, zur Erhohung der Akzeptanz staatlicher Masnahmen.

At the beginning of 2007 the Governmental Institute of Public Health of Lower Saxony, Germany (NLGA), initialised a project for the public health service (OGD) of Lower Saxony to establish the serological tuberculin test (interferon-γ release assay, IGRA) for contact tracing. So far contact tracing was done inconsistently in Lower Saxony. Up to now the main diagnostic method for detecting a latent tuberculosis was the radiographic test as well as the tuberculin skin test. But both methods are not suitable for detecting a latent tuberculosis because of their low sensitivity and specificity. At the beginning of the project the OGD was recommended to use a two-stage procedure. First, the tuberculin skin test should be made and in case of a positive reaction testing with IGRA should follow. After 2 years 37 (80.4%) of the 46 administrative districts have established the IGRA for tuberculosis contact tracing. A positive result of the tuberculin skin test could not be certified by IGRA for about 558 (65.4%) of the tested persons. This means that 2/3 of close contact persons with a positive skin test could be excluded from contact tracing and for them no further examination was necessary. Because of this result of the project, the IGRA now is a freeof-charge analysis at the NLGA for the OGD.

INTRODUCTION: In spring 2007a cluster of nosocomial salmonellosis cases, culture confirmed for SALMONELLA Enteritidis lysotype (LT) 8 / 7, occurred in a Wolfsburg hospital. An outbreak investigation was initiated to determine the epidemiology of the outbreak and to identify and control the possible sources. METHODS: A multidisciplinary outbreak team was formed including members from hospital hygiene and local, state and national health and veterinarian authorities. Active surveillance was set up in the hospital to find new cases. A retrospective case control study was conducted to identify possible risk factors for disease. Hospital workers and food samples were tested for the pathogen and positive isolates were typed. RESULTS: Between calendar weeks 4 and 24 of the year 2007, a total of 28 patients with a median age 66 years had nosocomial salmonellosis culture confirmed for SALMONELLA Enteritidis LT 8 / 7. In food samples from February, the same Salmonella lysotype was isolated in 4 different food samples. SALMONELLA Enteritidis LT 8 / 7 was also identified in stool samples from 5 kitchen personnel. The case control study indicated antacida therapy (odds ratio: 5.5, 95 % CI 1.2 - 26.0) as a risk factor for nosocomial salmonellosis among patients. No particular diet was associated with an increased risk of disease. DISCUSSION: This nosocomial salmonellosis outbreak was characterised by prolonged duration and a low infection rate among patients. The epidemiological investigation suggests that the origin of the outbreak was food that was probably associated with a contamination in the hospital kitchen. Furthermore, kitchen staff could, as carriers, have contributed to a low-level contamination of various foods for a long period. The intermittent occurrence of the cases is best explained by a low level of contaminated food which primarily led to clinical symptoms among especially vulnerable persons (older patients with antacida therapy). Considering the unusual progression of this outbreak, hospitals should initiate an intensive epidemiological and microbiological investigation, even if only few nosocomial salmonellosis cases occur.

Background In the German federal state of Lower-Saxony the districts are responsible for conducting school entry health examinations. There exist two different standard protocols for diagnosis and documentation, denoted as Weser-Ems (WE) and SOPHIA. In order to analyse and improve the comparability between these two protocols, a working group was established in 2006. One of the objectives was to adjust the protocols in such a way that in the future the collected data will allow for joint health reporting. Methods Each variable was discussed individually by the working group, and if diagnosis or documentation differed between the two protocols, specific modifications were proposed. For certain variables external expert opinions were obtained. For those variables that had to be revised quite generally, specific sub-working groups were established. As prerequisite for implementation, the recommendations of the working group had to be accepted by the user groups through majority votes. Results Of 88 (WE) or, respectively, 66 (SOPHIA) variables, 39 (WE) or, respectively, 34 variables initially fulfilled the requirements for a joint analysis. As a result of the working group, for more than 20 other variables the requirements for a joint analysis could be achieved. As soon as the sub-working groups have completed their work, also the issues of physical coordination, cognitive abilities and psychological health will be available for joint analysis. Discussion The synchronisation of school entry health examinations in Lower-Saxony is an example of how different protocols of diagnosis and documentation can be adapted to each other to enable joint data analysis without loosing their individual characteristics.

Background A birth cohort dedicated to studying infections in early childhood may be assisted by parental recording of symptoms on a daily basis and a collection of biomaterials. We aimed at testing the feasibility of this approach for use in a long-term study focusing on infections in children in Germany. Methods Parents of 1- to 3-year-old children (n = 75) were recruited in nursery schools. They were asked to complete a symptom diary on a daily basis and to take monthly and symptom-triggered nasal swabs and stool samples from their child over the study period of three months. Feasibility was measured by means of the return proportions of symptom diaries and bio samples; acceptance was assessed by a questionnaire delivered to participants at the end of the study. Results The majority of the participants filled in the symptom diary during the three months study for 75 or more days (77.3 %), and provided the monthly nasal swabs (62.7 %) and stool samples (65.3 %). The time needed for the tasks was acceptable for most participants (symptom diary: 92.3 %, nasal swabs: 98.5 %, stool samples: 100.0 %). In 64.3 % of the symptom-triggered nasal swabs, respiratory viruses were found compared to 55.5 % in throat swabs taken by health-care professionals within the “ARE surveillance Lower Saxony”, a special project by the Governmental Institute of Public Health of Lower Saxony to investigate causal pathogens for acute respiratory infections in children. Conclusions The parental assessment of symptoms and collection of biomaterials in a birth cohort dedicated to studying infections appears feasible in a middle class German population. The success of the study will depend on the ability to maintain these activities over a long time period. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1189-0) contains supplementary material, which is available to authorized users.

SUMMARYTo investigate risk factors for sporadic salmonellosis, for each notified case four randomly selected population controls matched for age, sex and geographical region were interviewed via self-administered questionnaire. Conditional logistic regression analysis of 285 matched pairs revealed significant associations for raw ground pork consumption [odds ratio (OR) 6·0, 95% confidence interval (CI) 1·8–20·1], taking antacids (OR 5·8, 95% CI 1·4–24·5), eating meat outside the home (OR 5·7, 95% CI 2·2–14·6) and daily changing or cleaning of dishcloth (OR 2·1, 95% CI 1·2–3·9). Animal contact and ice cream consumption were negatively associated with salmonellosis (OR 0·5, 95% CI 0·2–1 and OR 0·3, 95% CI 0·1–0·6, respectively).S.Typhimurium infections were significantly associated with raw ground pork consumption (OR 16·7, 95% CI 1·4–194·4) andS.Enteritidis infections with having travelled abroad (OR 9·7, 95% CI 2·0–47·3). Raw egg consumption was not a risk factor, substantiating the success of recently implemented national control programmes in the poultry industry. Unexpectedly, hygienic behaviour was more frequently reported by cases, probably because they overestimated their hygiene precautions retrospectively. Although animal contact might enhance human immunocompetence, underreporting of salmonellosis by pet owners could have occurred. Eating raw pork products is the major risk factor for sporadic humanS.Typhimurium infections in Lower Saxony.

In the context of influenza pandemic preparedness planning, a surveillance system for influenza and other acute respiratory illnesses was implemented in Lower Saxony at the beginning of the influenza season 2004/2005 and coordinated by the Governmental Institute of Public Health of Lower Saxony. This surveillance system represents an addition to already existing national monitoring systems. The goal of this surveillance system is to have available prompt information on the beginning, course and end of the influenza season and to recognise the spectrum of pathogens and identify outbreaks of other viral acute respiratory illnesses (ARI). For this purpose an all-season surveillance was established consisting of two supplementary modules. The first module is a symptom-oriented surveillance of acute respiratory illnesses in children of pre-school day care facilities. In the second module a virological surveillance in co-operation with selected medical practices was established. While the temporal course and burden of ARI in all Lower Saxony can be assessed by the surveillance of children in the day-care facilities in a sensitive, but less specific way, the virological surveillance provides highly specific information on the prevailing pathogens in ARI patients at a certain time. This information, in return, gives an indication about the responsible pathogens causing ARI in children of the day-care facilities. The first experience with these two complementary surveillance modules shows that in Lower Saxony a well accepted, prompt and meaningful monitoring system is available for the recognition and description of the occurrence of ARI and concomitantly of influenza. An extension of this surveillance to other pathogens or disease scenarios is possible.

BACKGROUND In Lower Saxony the analysis of notification data according to the infection protection law is based on two pillars: one pillar is the weekly analysis to identify clusters and locally non-detectable outbreaks by an early warning system. The second pillar is an annual reporting system for obtaining an overall picture and for identifying long-term trends. In both fields methods of spatial statistics are applied. METHODS For the 16 most frequent notifiable diseases, the notification data of the districts of Lower Saxony are analysed and presented on the Internet. The presentation starts with an overview page, on which differences between observed and expected case counts for these diseases are presented tabulated and graphically. On a separate page for each disease the temporal and spatial distribution is shown by means of the following graphs: Time series presentation (weekly case counts and moving averages), chloropleth map of regional incidence rates and dot map of regional case counts. For identification of outbreaks, Kulldorff's "scan statistic" is used to search the data for clusters and to assess the significance of these clusters. The methods are executed mainly automatically using predominantly public domain software. RESULTS AND DISCUSSION The approach attempts to meet the surveillance principle of providing the participants with immediate feedback. The scan statistics is a universal objective instrument for detecting and assessing spatial clusters. A special advantage is the identification of clusters which include several districts. The properties of the identified clusters (spatial extension, number of cases) offer some insight into the characteristic epidemiology of the diseases.

In Lower Saxony, a regional public health project for an enlarged surveillance of viral hepatitis was carried out from 1999 to 2001. Five district public health authorities collected additional information on notified viral hepatitis cases in a standardised way, particularly regarding risk factors. In the survey, 270 hepatitis (hep.) cases were investigated, among them hep. A 51 (18.9%), hep. B 87 (32.2%) and hep. C 132 (48.9%). The proportion of chronic cases and healthy carriers was as follows: hep. A 0%, hep. B 47.1% and hep. C 79.5%. In approximately 50% of the cases of all three forms risk factors could be identified. The most frequent risk factors were in hep. A visits to foreign countries (29.4%), contacts to infected individuals (17.6%) and attendance at public institutions or care facilities (13.7%), in hep. B visits to foreign countries (24.1%), contacts to infected individuals (19.5%; sexual contacts 16.1%) and medical treatments (19.5%) and in hep. C injecting drug use (31.1%) and medical treatments (18.2%; 9.8% blood transfusion in the past in combination with chronic hep. C). The results are in accordance with current data under the new infection protection law, where reporting of chronic cases was mostly abolished. In the survey, the well-known risk factors were confirmed, but some risks were reported more frequently than in other surveys, e. g. sexual behaviour for hep. B or injecting drugs for hep. C.

Seven schools in Lower Saxony participated in a scientific research project measuring the concentration of carbon dioxide (CO 2 ), indoor air temperatures and the relative air humidity in naturally ventilated classrooms on 58 days during the period of one year. The results are as follows: - The hygienic reference value of 1500 ppm CO 2 (in accordance with the official German regulation DIN 1946-2) was exceeded on 7 days in summer when measurements were taken (32% of all samples in summer) and on 32 days in winter (89% of all samples in winter). - The mean CO 2 -concentration was 1316 ppm, 766 ppm and 1652 ppm in all samples (58 measuring days), summer samples (22 measuring days) and winter samples (36 measuring days), respectively. The mean indoor air temperature was 21.7°C, 22.9°C and 20.9 C. The mean relative humidity was 50.7%, 54.3% and 48.5%. - The mean number of persons per classroom (including the teacher) was 25.1, corresponding to a mean volume of 8.5 m 3 for each person and a mean area of 2.9 m 2 per person. - A statistical association of CO 2 concentration with season, outdoor temperature and the age of the windows was found. - A software programme has been developed for calculating the concentration of CO 2 depending on the number of persons and the ventilation rate in a classroom. - A 3-level scheme based on CO 2 concentration was developed to assess the air quality. The results showed that the classrooms were not ventilated regularly but depending on the outdoor temperature and the season. Deficits concerning all 3 parameters were found. It is very likely that the deficits are not limited to the schools participating in this project. Ventilation and indoor climate deficits might cause health problems and therefore lead to costly measurement programmes. To enable schools to take their own health-related measurements, measuring instruments were purchased which can be loaned to schools in Lower Saxony.

Objective and Method: In cooperation with the district public health authorities in Lower Saxony a surveillance system for infections of the central nervous system was established from 1998 to 2000. Reporting was based on special questionnaires. It was the objective of this system to obtain information on the pathogens responsible for these infections and the corresponding age distribution. Results: An increased risk was found for children under the age of 15. About two-thirds of all reported central nervous infections were observed in this age group. The most frequent bacteria identified had been Meningococci, Pneumococci and Borrellia burgdorferi. They accounted for about 56% of the reported bacterial infections. With respect to viral meningitis/encephalitis, enteroviruses were isolated in about 66% of these cases. Twenty-five of all 628 reported cases had a lethal outcome which was more often associated with bacterial than viral infections. Conclusions: Infections of the central nervous system still play an important role in clinical and public health medicine. For the future an intensive and ongoing surveillance of these infectious diseases is required and should exceed the regulations of the official notification system. To this end, a prospective register for meningitis and encephalitis cases will be set up in Lower Saxony in cooperation with hospitals and laboratories.

SUMMARYWe conducted a case-control study based on 884 laboratory-confirmed sporadicSalmonellacases reported to the German infectious disease notification system. For controls, we recruited 510 rotavirus cases via the same system. Univariable and multivariable logistic regression analyses were performed separately for children aged 0–3 years and 4–14 years. In both age groups, the highest odds ratios (OR) were found for raw ground pork consumption [0–3 years: OR 8·6, 95% confidence interval (CI) 2·4–30·8; 4–14 years: OR 4·5, 95% CI 1·1–19]. Further risk factors were exposure to animals (OR 1·6, 95% CI 1·1–2·1), consumption of poultry (OR 1·5, 95% CI 1·1–2·1), food items containing eggs (OR 1·5, 95% CI 1·1–2) and black pepper (OR 1·7, 95% CI 1·1–3·5) in children aged 0–3 years, and consumption of uncooked pork sausage (OR 3·6, 95% CI 1·4–9·3) in children aged 4–14 years. This study highlights the significance of raw pork products (‘Mett’ in German) as risk factors for sporadic salmonellosis in children in Germany.

In Lower Saxony, a regional public health project on a pathogen-specific surveillance of Enteritis infectiosa was carried out from 1994 to 2000. In a separate reporting procedure thirteen health departments transmitted data on the specific pathogen collected from laboratory reports for a joint analysis. The results were distributed among the participants, providing them with information on the situation and trends in their districts and in addition giving them the possibility to compare their data with those of other districts. The incidence of Enteritis infectiosa was 199 reported cases per 100,000 person years. Salmonella was reported most frequently (51 %; S. enteritidis: 33 %, S. TYPHIMURIUM: 14 %, 111 other serotypes: 4 %), followed by Campylobacter (18 %), Rotavirus (17 %), Yersinia enterocolitica (6 %) and Adenovirus (5 %). The incidences of Salmonella and Yersinia enterocolitica were found to be nearly constant over the project period while the incidences of Campylobacter, Rotavirus and Adenovirus increased. This, however, may be due to intensified diagnostics and better reporting behaviour rather than to a real increase. The incidence rates and their trends differed from other German states. This observation emphasizes the need for a regional analysis of infectious disease surveillance data.

Antimicrobial resistance is one of the most important health topics of the past few years. To identify regional trends of antimicrobial resistance in inpatient and outpatient care, the Governmental Institute of Public Health of Lower Saxony (Germany) launched the sentinel system ARMIN (Antimicrobial Resistance Monitoring in Lower Saxony). Currently 9 laboratories participate as sentinel sites and contribute single case data of their microbiological results. Data are presented by an interactive data query in the internet. From 2006 to 2010 laboratories reported about 800 000 diagnostic test results. The proportion of MRSA (methicillin-resistant Staphylococcus aureus) among all Staphylococcus aureus increased from 19.5% in 2006 to 23.4% in 2010 for inpatient care in Lower Saxony. During the same period Escherichia coli resistance to cefotaxime for inpatient care increased from 3.0% to 8.8%. Enterococcus faecium resistance to vancomycin decreased from 13.6% to 5.6%. Currently the emphasis of ARMIN is on the description of trends and on the information of prescribing physicians. A quality circle was established to improve standardisation.

A large outbreak of the hemolytic-uremic syndrome caused by Shiga-toxin-producing Escherichia coli O104:H4 occurred in Germany in May 2011. The source of infection was undetermined.We conducted a matched case-control study and a recipe-based restaurant cohort study, along with environmental, trace-back, and trace-forward investigations, to determine the source of infection.The case-control study included 26 case subjects with the hemolytic-uremic syndrome and 81 control subjects. The outbreak of illness was associated with sprout consumption in univariable analysis (matched odds ratio, 5.8; 95% confidence interval [CI], 1.2 to 29) and with sprout and cucumber consumption in multivariable analysis. Among case subjects, 25% reported having eaten sprouts, and 88% reported having eaten cucumbers. The recipe-based study among 10 groups of visitors to restaurant K included 152 persons, among whom bloody diarrhea or diarrhea confirmed to be associated with Shiga-toxin-producing E. coli developed in 31 (20%). Visitors who were served sprouts were significantly more likely to become ill (relative risk, 14.2; 95% CI, 2.6 to ∞). Sprout consumption explained 100% of cases. Trace-back investigation of sprouts from the distributor that supplied restaurant K led to producer A. All 41 case clusters with known trading connections could be explained by producer A. The outbreak strain could not be identified on seeds from the implicated lot.Our investigations identified sprouts as the most likely outbreak vehicle, underlining the need to take into account food items that may be overlooked during subjects' recall of consumption.

In order to establish a joint pandemic strategy, the German states ("Länder") together with the German federal government ("Bund") agreed on joint preparations for pandemic scenarios. This included the description of procedures, such as infection control measures, stockpiling of antiviral drugs, and contracts with vaccine manufacturers to ensure supply of vaccines in the event of a pandemic. The situation during the influenza H1N1 pandemic differed from that planned so that many short-term adjustments were required. It highlighted the need to make pandemic planning more flexible. In spite of several obstacles which had to be overcome during the situation, the states managed to achieve a relatively coordinated procedure and provided the availability of vaccines. In the course of the pandemic, gaps and shortcoming in existing surveillance systems were identified, which should lead to further improvements. A key point for future pandemic events is successful communication between all interested parties, especially with the medical profession, to increase the acceptance of public policies.

This paper discusses computer-supported outbreak detection using routine surveillance data, as implemented at six institutes for infectious disease control in five European countries. We give an overview of the systems used at the Statens Serum Institut (Denmark), Health Protection Agency (England, Wales and Northern Ireland), Robert Koch Institute (Germany), Governmental Institute of Public Health of Lower Saxony (Germany), National Institute for Public Health and the Environment (the Netherlands) and Swedish Institute for Infectious Disease Control (Sweden). Despite the usefulness of the algorithms or the outbreak detection procedure itself, all institutes have experienced certain limitations of the systems. The paper therefore concludes with a list of recommendations for institutes planning to introduce computer-supported outbreak detection, based on experiences on the practical usage of the systems. This list - which concerns usability, standard operating procedures and evaluation - might also inspire improvements of systems in use today. .