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ZusammenfassungIm Rahmen der nationalen Influenzapandemieplanung wurden in Deutschland neben dem Meldewesen gemäß Infektionsschutzgesetz (IfSG) weitere Überwachungssysteme etabliert. Ziel dieser Systeme sind die Beschreibung, Analyse und Bewertung der Situation bei akuten respiratorischen Erkrankungen (ARE), die Identifikation der hauptsächlich zirkulierenden Atemwegserreger und die Beschreibung des zeitlichen Verlaufs. Seit Beginn der COVID-19-Pandemie wurden die Systeme erweitert, um auch Infektionen mit SARS-CoV‑2 erfassen zu können.In diesem Beitrag werden drei verschiedene Surveillance-Systeme für ARE vorgestellt: GrippeWeb, die Arbeitsgemeinschaft Influenza mit dem SEEDARE-Modul (Sentinel zur elektronischen Erfassung von Diagnosecodes) und das Krankenhaus-Sentinel ICOSARI (ICD-10-code-basierte Krankenhaus-Surveillance schwerer akuter respiratorischer Infektionen). Mit diesen Systemen können ARE auf Bevölkerungsebene, im ambulanten und im stationären Bereich überwacht werden. Zusammen mit dem Monitoring der Mortalität liefern sie wichtige Hinweise zur Häufigkeit verschieden schwerer Krankheitsverläufe in der Bevölkerung. Um die Systeme für SARS-CoV‑2 zu erweitern, waren nur wenige Anpassungen notwendig.Da die Falldefinitionen für ARE nicht geändert wurden, können in den beschriebenen Systemen historische Zeitreihen zum Vergleich herangezogen werden. Alle Systeme sind so aufgebaut, dass stabile und etablierte Bezugsgrößen für die Berechnung von wöchentlichen Anteilen und Raten zur Verfügung stehen. Dies ist eine wichtige Ergänzung zum Meldewesen gemäß IfSG, welches stark von Testkapazitäten und -strategien sowie veränderten Falldefinitionen abhängt. Die Surveillance-Systeme haben sich in der COVID-19-Pandemie auch im internationalen Vergleich als praktikabel und effizient erwiesen.

ObjectiveThe emergence of coronavirus disease 2019 (COVID-19) required countries to establish COVID-19 surveillance by adapting existing systems, such as mandatory notification and syndromic surveillance systems. We estimated age-specific COVID-19 hospitalization and intensive care unit (ICU) burden from existing severe acute respiratory infections (SARI) surveillance and compared the results to COVID-19 notification data.MethodsUsing data on SARI cases with ICD-10 diagnosis codes for COVID-19 (COVID-SARI) from the ICD-10 based SARI sentinel, we estimated age-specific incidences for COVID-SARI hospitalization and ICU for the first five COVID-19 waves in Germany and compared these to incidences from notification data on COVID-19 cases using relative change Δrat the peak of each wave.FindingsThe COVID-SARI incidence from sentinel data matched the notified COVID-19 hospitalization incidence in the first wave with Δr=6% but was higher during second to fourth wave (Δr=20% to 39%). In the fifth wave, the COVID-SARI incidence was lower than the notified COVID-19 hospitalization incidence (Δr=-39%). For all waves and all age groups, the ICU incidence estimated from COVID-SARI was more than twice the estimation from notification data.ConclusionThe use of validated SARI sentinel data adds robust and important information for assessing the true disease burden of severe COVID-19. Mandatory notifications of COVID-19 for hospital and ICU admission may underestimate (work overload in local health authorities) or overestimate (hospital admission for other reasons than the laboratory-confirmed SARS-CoV-2 infection) disease burden. Syndromic ICD-10 based SARI surveillance enables sustainable cross-pathogen surveillance for seasonal epidemics and pandemic preparedness of respiratory viral diseases.

Im Rahmen der nationalen Influenzapandemieplanung wurden in Deutschland neben dem Meldewesen gemäß Infektionsschutzgesetz (IfSG) weitere Überwachungssysteme etabliert. Ziel dieser Systeme sind die Beschreibung, Analyse und Bewertung der Situation bei akuten respiratorischen Erkrankungen (ARE), die Identifikation der hauptsächlich zirkulierenden Atemwegserreger und die Beschreibung des zeitlichen Verlaufs. Seit Beginn der COVID-19-Pandemie wurden die Systeme erweitert, um auch Infektionen mit SARS-CoV‑2 erfassen zu können. In diesem Beitrag werden drei verschiedene Surveillance-Systeme für ARE vorgestellt: GrippeWeb, die Arbeitsgemeinschaft Influenza mit dem SEEDARE-Modul (Sentinel zur elektronischen Erfassung von Diagnosecodes) und das Krankenhaus-Sentinel ICOSARI (ICD-10-code-basierte Krankenhaus-Surveillance schwerer akuter respiratorischer Infektionen). Mit diesen Systemen können ARE auf Bevölkerungsebene, im ambulanten und im stationären Bereich überwacht werden. Zusammen mit dem Monitoring der Mortalität liefern sie wichtige Hinweise zur Häufigkeit verschieden schwerer Krankheitsverläufe in der Bevölkerung. Um die Systeme für SARS-CoV‑2 zu erweitern, waren nur wenige Anpassungen notwendig. Da die Falldefinitionen für ARE nicht geändert wurden, können in den beschriebenen Systemen historische Zeitreihen zum Vergleich herangezogen werden. Alle Systeme sind so aufgebaut, dass stabile und etablierte Bezugsgrößen für die Berechnung von wöchentlichen Anteilen und Raten zur Verfügung stehen. Dies ist eine wichtige Ergänzung zum Meldewesen gemäß IfSG, welches stark von Testkapazitäten und -strategien sowie veränderten Falldefinitionen abhängt. Die Surveillance-Systeme haben sich in der COVID-19-Pandemie auch im internationalen Vergleich als praktikabel und effizient erwiesen.

Information on severity of coronavirus disease (COVID-19) (transmissibility, disease seriousness, impact) is crucial for preparation of healthcare sectors. We present a simple approach to assess disease seriousness, creating a reference cohort of pneumonia patients from sentinel hospitals. First comparisons exposed a higher rate of COVID-19 patients requiring ventilation. There were more case fatalities among COVID-19 patients without comorbidities than in the reference cohort. Hospitals should prepare for high utilisation of ventilation and intensive care resources.

Die Revision der Internationalen statistischen Klassifikation der Krankheiten und verwandter Gesundheitsprobleme (International Classification of Diseases – ICD) geht mit grundlegenden Anderungen der Morbiditats- und Mortalitatsstatistik einher, die auch den Bereich der Infektionskrankheiten betreffen. Die Zuordnung der einzelnen Infektionskrankheiten zu den Kapiteln in der aktuellen ICD-10 erfolgt aufgrund unterschiedlicher Konzepte, teilweise nach auslosendem Agens, nach betroffenem Organsystem oder nach Lebensperiode. Besondere Herausforderungen der Klassifizierung der Infektionskrankheiten bestehen u. a. darin, dass regelmasig ein Anpassungsbedarf durch neu auftretende Erreger entstehen kann. Auserdem reichen die Angaben hinsichtlich Umfang und Tiefe in der ICD-10 teilweise nicht aus, um epidemiologische Auswertungen der Daten durchzufuhren. Die ICD ermoglicht den weltweiten Vergleich von Statistiken zu Infektionskrankheiten. Zunehmend wird die ICD jedoch auch fur die Erhebung von Surveillance- und Forschungsdaten eingesetzt, z. B. im Rahmen des Meldewesens (Identifizierung von Meldetatbestanden), aber auch in der syndromischen Surveillance akuter Atemwegsinfektionen und fur den Aufbau neuer Surveillance-Systeme sowie der Evaluation der Datenqualitat durch Abgleich mit Sekundardaten. Die Chancen der ICD-11 liegen vor allem darin, dass Infektionskrankheiten eindeutiger codiert werden konnen und ihre Codierung mehr relevante Informationen fur die epidemiologische Bewertung enthalt. Durch die hohe Komplexitat konnen jedoch Verzerrungen in den Daten entstehen, die die Fortschreibung der Morbiditats- und Mortalitatsstatistiken erschweren.

Mit der Aufnahme einer allgemeinen Varizellenimpfung fur Sauglinge ab einem Alter von 11 Lebensmonaten im Jahr 2004 und der Empfehlung einer zweiten Impfung im Jahr 2009 wurde in Deutschland eine neue Impfung eingefuhrt, die zeitgleich mit der gegen Masern, Mumps und Roteln (MMR) durchgefuhrt wird. Die mit der Impfung implementierte Sentinelsurveillance der Arbeitsgemeinschaft Varizellen belegt, dass infolge der bisher erreichten Impfquoten die Ziele der Impfung (Reduktion der Varizellenmorbiditat und der Varizellen-bedingten Komplikationen und Krankenhausbehandlungen) innerhalb weniger Jahre erreicht wurden. Obgleich die Impfquoten fur die Varizellenimpfung die der MMR-Impfung noch nicht vollstandig erreicht haben, scheint die Varizellenimpfung von der etablierten MMR-Impfung profitiert zu haben. Umgekehrt lassen sich keine nachteiligen Auswirkungen auf die Inanspruchnahme der MMR-Impfung nachweisen. Erfahrungen aus der Masernepidemiologie (wie z. B. Trends der Erkrankungshaufigkeit bei Jugendlichen und Sauglingen) wie auch aus der Historie der Impfempfehlungen gegen Masern konnen wichtige Hinweise bei der Bewertung der epidemiologischen Veranderungen bezuglich Varizellen und Herpes zoster geben. Vor dem Hintergrund der nach einer Impfung relativ rasch schwindenden Immunitat („waning immunity“) gegenuber dem Varizella-zoster-Virus und der lebenslangen Persistenz des Virus sind der Aufbau und der Erhalt einer robusten und nachhaltigen Immunitat in der gesamten Bevolkerung ein anspruchsvolles Ziel, um Durchbruchsinfektionen, eine Alters-Rechtsverschiebung der Varizellenerkrankungen und Inzidenzanstiege des Zoster dauerhaft zu vermeiden.

Background Syndromic surveillance of severe acute respiratory infections (SARI) is important to assess seriousness of disease as recommended by WHO for influenza. In 2015 the Robert Koch Institute (RKI) started to collaborate with a private hospital network to develop a SARI surveillance system using case-based data on ICD-10 codes. This first-time description of the system shows its application to the analysis of five influenza seasons. Methods Since week 40/2015, weekly updated anonymized data on discharged patients overall and on patients with respiratory illness including ICD-10 codes of primary and secondary diagnoses are transferred from the network data center to RKI. Retrospective datasets were also provided. Our descriptive analysis is based on data of 47 sentinel hospitals collected between weeks 1/2012 to 20/2016. We applied three different SARI case definitions (CD) based on ICD-10 codes for discharge diagnoses of respiratory tract infections (J09 - J22): basic CD (BCD), using only primary diagnoses; sensitive CD (SCD), using primary and secondary diagnoses; timely CD (TCD), using only primary diagnoses of patients hospitalized up to one week. We compared the CD with regard to severity, age distribution and timeliness and with results from the national primary care sentinel system. Results The 47 sentinel hospitals covered 3.6% of patients discharged from all German hospitals in 2013. The SCD comprised 2.2 times patients as the BCD, and 3.6 times as many as the TCD. Time course of SARI cases corresponded well to results from primary care surveillance and influenza virus circulation. The patients fulfilling the TCD had been completely reported after 3 weeks, which was fastest among the CD. The proportion of SARI cases among patients was highest in the youngest age group of below 5-year-olds. However, the age group 60 years and above contributed most SARI cases. This was irrespective of the CD used. Conclusions In general, available data and the implemented reporting system are appropriate to provide timely and reliable information on SARI in inpatients in Germany. Our ICD-10-based approach proved to be useful for fulfilling requirements for SARI surveillance. The exploratory approach gave valuable insights in data structure and emphasized the advantages of different CD.

Objectives Vaccine effectiveness (VE) of 1 and 2 varicella vaccine doses in children aged 1-4 years in Germany was evaluated to determine the additional effect of a second dose recommended at least 4 weeks after the first dose and before the second birthday. Study design To estimate the VE, the proportion of cases vaccinated was compared with the proportion of the population vaccinated using nationwide sentinel surveillance data from 2009-2014 and health insurance claims data covering the period January 2009-March 2014, respectively. A general linear model was used to estimate the OR of vaccination in the cases and the population and the corresponding CIs to observe the stability of the VE estimates over time, and to assess the incremental effectiveness of a second dose. Results The overall VE after 1 dose was 86.6% (95% CI: 85.2-87.9), ranging between 94.6% (95% CI: 87.9-97.6) in the first quarter of 2011 and 50.3% (95% CI: 7.3-73.4) in the third quarter of 2013. The overall VE after 2 doses was 97.3% (95% CI: 97.0-97.6), ranging between 99.5% (95% CI: 97.8-99.9) in the second quarter of 2009 and 91.3% (95% CI: 85.7-94.8) in the third quarter of 2013. The incremental VE of 2 doses was 84.6% (95% CI: 81.7-86.9). Conclusions The substantially higher VE of 2 varicella vaccine doses compared with 1 dose in young children and the strong additional effect of the second dose support the public health relevance of a 2-dose schedule and the success of the early second vaccine dose.

Accompanying varicella vaccination in children in Germany recommended with one (2004) and two (2009) doses, sentinel surveillance of varicella with a sample (n∼900) of private physicians was established in 2005. Physicians reported monthly aggregated data on all varicella cases and case-based on vaccinated patients, of whom skin lesion samples were laboratory investigated to identify varicella-zoster virus (VZV). We analyzed the impact of vaccination frequency on the number of cases and on laboratory results within the sentinel.Swabs were obtained with a Teflon tip and sent together with a case-based questionnaire to the reference laboratory. VZV wild-type and vaccine-type was identified by polymerase chain-reaction (PCR) and pyrosequencing methods. Case-based data and laboratory results were analyzed descriptively.From April 2005 to March 2014, of all monthly reported cases (n=111,456) 4789 were vaccinated and eligible for further analysis. No differences were found between laboratory investigated and not investigated cases (1017 vs. 3772) except that the proportion of cases vaccinated twice was higher in lab-cases (29.4% vs. 16.1%). PCR remained negative in 69.6% (197/283) of breakthrough-cases vaccinated twice, in comparison to 22.7% (147/649) breakthrough-cases vaccinated once. VZV was confirmed in 500 (81) patients with breakthrough varicella after one (two) vaccination(s); identification of VZV wild-type, vaccine-type, or no further differentiation was possible in 485 (72), 5 (6), and 10 (3) cases, respectively.Varicella breakthrough disease is rare in Germany and suspected clinical cases require laboratory confirmation. The lower confirmation rate of VZV after two vaccine doses suggests a better protection compared to one dose.

BACKGROUND: In August 2011, the German Protection against Infection Act was amended, mandating the reporting of healthcare associated infection (HAI) outbreak notifications by all healthcare workers in Germany via local public health authorities and federal states to the Robert Koch Institute (RKI). OBJECTIVE: To describe the reported HAI-outbreaks and the surveillance system's structure and capabilities. METHODS: Information on each outbreak was collected using standard paper forms and notified to RKI. Notifications were screened daily and regularly analysed. RESULTS: Between November 2011 and November 2012, 1,326 paper forms notified 578 HAI-outbreaks, between 7 and 116 outbreaks per month. The main causative agent was norovirus (n = 414/578; 72%). Among the 108 outbreaks caused by bacteria, the most frequent pathogens were Clostridium difficile (25%) Klebsiella spp. (19%) and Staphylococcus spp. (19%). Multidrug-resistant bacteria were responsible for 54/108 (50%) bacterial outbreaks. Hospitals were affected most frequently (485/578; 84%). Hospital outbreaks due to bacteria were mostly reported from intensive care units (ICUs) (45%), followed by internal medicine wards (16%). CONCLUSION: The mandatory HAI-outbreak surveillance system describes common outbreaks. Pathogens with a particular high potential to cause large or severe outbreaks may be identified, enabling us to further focus research and preventive measures. Increasing the sensitivity and reliability of the data collection further will facilitate identification of outbreaks able to increase in size and severity, and guide specific control measures to interrupt their propagation.

In March 2011, the German sentinel surveillance system for influenza (Arbeitsgemeinschaft Influenza (AGI)) was complemented by an Internet-based syndromic monitoring system (GrippeWeb) for acute respiratory infections (ARI) and influenza-like-illness (ILI). To assess representativeness of GrippeWeb participants, key demographic variables and lifetime prevalence of asthma and diabetes were compared with data from the general population of Germany. To 'validate' GrippeWeb, we compared weekly ARI and medically attended ARI (MAARI) rates, generated between weeks 35/2011 and 34/2012, with AGI MAARI rates and overlaid GrippeWeb ILI rates with the number of positive influenza samples obtained by the AGI. GrippeWeb had high weekly participation rates (62% of participants reported in ≥90% of possible weeks). Although it varied by age group, participants reported a mean of between 1.3 and 6.0 ARI episodes and between 0.1 and 2.4 ILI episodes during the study year. Estimated GrippeWeb MAARI incidence was very similar to the AGI MAARI incidence and influenza circulation was reflected well in the GrippeWeb ILI rates. GrippeWeb became a reliable monitoring system shortly after implementation, capturing the burden of ARI and ILI at general population level. The high degree of agreement between GrippeWeb's and AGI's MAARI data lends support to the validity of both systems. .

Tuberculosis (TB) surveillance commonly focuses on pulmonary (PTB) where the main organ affected is the lung. This might lead to underestimate extrapulmonary TB (EPTB) forms, where in addition to the lung other sites are affected by TB. In Germany, TB notification data provide the main site and the secondary site of disease. To gain an overview of all the different EPTB forms, we analysed German TB notification data between 2002 and 2009 using information on both main and secondary disease site to describe all individual EPTB forms. Further, we assessed factors associated with meningitis using multivariable logistic regression. Solely analysing the main site of disease, lead to one third of EPTB manifestations being overlooked. Case characteristics varied substantially across individual extrapulmonary forms. Of 46,349 TB patients, 422 (0.9%) had meningitis as main or secondary site. Of those, 105 (25%) of the 415 with available information had died. Multivariable analysis showed that meningitis was more likely in children younger than five years and between five and nine years-old (odds ratio (OR): 4.90; 95% confidence interval (CI): 3.40–7.07 and OR: 2.65; 95% CI: 1.40–5.00), in females (OR: 1.42; 95% CI: 1.17–1.73), and in those born in the World Health Organization (WHO) regions of south-east Asia (OR: 2.38; 95% CI: 1.66–3.43) and eastern Mediterranean (OR: 1.51; 95% CI: 1.02–2.23). Overall, EPTB manifestations, including meningitis, which is often fatal, were underestimated by routine analysis. We thus recommend using all information on disease manifestation generated by surveillance to monitor severe forms and to transfer the gained knowledge to TB case management where awareness of EPTB is most important.

Based on voluntary examinations for Salmonella in laying hen flocks in Germany, it was investigated whether a statistically significant trend in Salmonella prevalence could be observed in the period 2003 to 2007. Furthermore, it was studied whether the implementation of Regulation (EC) No 1168/2006 led to an improvement of the collected data and a change in the Salmonella prevalence in 2008. To compensate for differences in data availability, submitted data were weighted by regional laying hen population size and compared with results from the non-weighted data. Between the years 2003 to 2007 a significant reduction of Salmonella prevalence could be observed. Weighting of data by population size improved trend recognition for routine sampling results. This may point towards a real reduction of Salmonella prevalence in German layer flocks in the years till 2007. The obligatory implementation of the control programme in 2008 led to a remarkable increase of examinations performed and an increased frequency of detection of Salmonella in flocks of laying hens. This tendency was statistically highly significant (p0,0042) for the overall dataset as well as for data from targeted sampling and other sampling. Again, after weighting data from routine sampling, a statistically significant (p0.05) increase of Salmonella prevalence could be shown. The two dominant serovars in human salmonellosis, namely S. Enteritidis and S. Typhimurium were most frequently observed in German laying hen flocks with S. Enteritidis being much more recurrent than S. Typhimurium. It is obvious from the available data that a good data quality is the prerequisite for a realistic evaluation of the Salmonella situation and that weighting may compensate for some of the bias inherent in the data reporting system.