A SARS-CoV-2 Omicron outbreak among crew members on a cruise ship in Germany in early 2022.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks on cruise ships have rarely been investigated. In early 2022, we were informed about a SARS-CoV-2 outbreak on a cruise ship calling Port of Hamburg after 10 infections among crew members were detected. We conducted an outbreak investigation in collaboration between ship owners, the ship physician and Hamburg's Institute for Hygiene and Environment, to identify risk factors and to achieve containment. The aim was to identify risk factors for SARS-CoV-2 infection and SARS-CoV-2 variants in a cohort of 165 crew members. MATERIALS AND METHODS: For this purpose, we collected data on age, sex, nationality, boarding-time, cabin use (single/shared), work place, and vaccination status of the study participants. Cases were defined as individuals who tested SARS-CoV-2 positive at least once in daily screenings during the outbreak period (10 days) by polymerase chain reaction or antigen test. We investigated risk factors for infection by descriptive, univariable and multivariable analysis. We performed whole genome sequencing to identify SARS-CoV-2 variants. RESULTS: We verified 103 SARS-CoV-2 positive cases (attack rate [AR] 62.4%); 39/41 sequenced samples were BA.2.3 Omicron subtype, one BA.1 and one BA.1.1. Among boostered crew members, AR was 38% vs. 65% among those vaccinated once or twice. Among those who stayed < 30 days on board, AR was 31% vs. 72% among those staying on board longer. Among Europeans, the AR was 53% vs. 71% in non- -Europeans. Adjusting for age and sex, cases were more likely to have received no booster vaccine (odds ratio [OR]: 2.66, 95% confidence interval [CI]: 0.99-7.13), to have spent more time on board (≥ 30 days, OR: 6.36, 95% CI: 2.81-14.40 vs. < 30 days) and to have a non-European nationality (OR: 2.14, 95% CI: 1.08-4.27). The outbreak stopped shortly after offboard isolation of cases. CONCLUSIONS: This investigation confirms the importance of a booster vaccine against COVID-19. Longer stays onboard could facilitate social mixing. Further studies could investigate the impact of social, cultural/ behavioural patterns and public health access on the infection risk. Physical distancing together with screening and isolation can contain SARS-CoV-2 outbreaks on cruise ships.

COVID-19 Outbreaks in Settings With Precarious Housing Conditions in Germany: Challenges and Lessons Learned.

Two COVID-19 outbreaks occurred in residential buildings with overcrowded housing conditions in the city of Göttingen in Germany during May and June 2020, when COVID-19 infection incidences were low across the rest of the country, with a national incidence of 2.6/100,000 population. The outbreaks increased the local incidence in the city of Göttingen to 123.5/100,000 in June 2020. Many of the affected residents were living in precarious conditions and experienced language barriers. The outbreaks were characterized by high case numbers and attack rates among the residents, many asymptomatic cases, a comparatively young population, and substantial outbreak control measures implemented by local authorities. We analyzed national and local surveillance data, calculated age-, and gender-specific attack rates and performed whole genome sequencing analysis to describe the outbreak and characteristics of the infected population. The authorities' infection control measures included voluntary and compulsory testing of all residents and mass quarantine. Public health measures, such as the general closure of schools and a public space as well as the prohibition of team sports at local level, were also implemented in the district to limit the outbreaks locally. The outbreaks were under control by the end of June 2020. We describe the measures to contain the outbreaks, the challenges experienced and lessons learned. We discuss how public health measures can be planned and implemented through consideration of the needs and vulnerabilities of affected populations. In order to avoid coercive measures, barrier-free communication, with language translation when needed, and consideration of socio-economic circumstances of affected populations are crucial for controlling infectious disease transmission in an outbreak effectively and in a timely way.

[Field investigations of SARS-CoV-2-outbreaks in Germany by the Robert Koch Institute, February-October 2020]. / Untersuchung von SARS-CoV-2-Ausbrüchen in Deutschland durch Feldteams des Robert Koch-Instituts, Februar­Oktober 2020.

The Robert Koch Institute (RKI) offers advice and assistance to local public health agencies on the investigation and management of outbreaks of infectious diseases. Specially trained experts conduct field investigations. During the COVID-19 pandemic, RKI experts participated in the investigation of outbreaks in residential buildings, physicians' offices, nursing homes, hospitals, and asylum seekers' facilities as well as at a night club and on a cruise ship.This report describes some of the field investigations conducted in Germany during the COVID-19 pandemic between February and October 2020. The investigations provided information on the properties of SARS-CoV­2 and its transmission as a basis for the recommendations on suitable prevention measures. The practical examples demonstrate the variety of support given as well as the opportunities to gather epidemiological evidence.In September 2020, the RKI established a new unit called the "Focal Point for the Public Health Service," which now coordinates and is expanding field support. In order to further support the public health system to improve its capability to react to and investigate outbreaks of infectious diseases, interdisciplinary training shall be intensified.

[Sustainable strengthening of Public Health in Germany through Attractive Career Paths - Core Requirements for a Public Health Strategy for Germany in the Area of Human Resources]. / Durch attraktive Karrierewege Public Health in Deutschland nachhaltig stärken ­ Kernforderungen an eine Public-Health-Strategie für Deutschland im Bereich Human Resources.

The demand for a well-trained public health workforce is increasing in view of the increased importance of health promotion and disease prevention in Germany. However, many career paths in public health are non-transparent, which creates additional barriers for interested young professionals and contributes to the existing gap between demand and supply. Against the backdrop of international frameworks and the specific labor market situation in Germany, the working group 11 "Career Paths in Public Health" of the 3rd Symposium of the Future Forum Public Health discussed current challenges and formulated initial solutions.

A large outbreak of influenza B-associated benign acute childhood myositis in Germany, 2007/2008.

BACKGROUND: Benign acute childhood myositis (BACM) is a rare syndrome associated with various viral infections. Bilateral calve pain may lead to inability to walk. During winter 2007/2008, we investigated a nationwide outbreak of influenza-associated BACM (IA-BACM) to identify etiologic (sub)type, describe the course of disease, and explore how well the syndrome is known among physicians. METHODS: We performed retrospective and prospective case finding in all German federal states. Physicians returned patient-based questionnaires containing information about sex, age, disease progression, patient-management, and number of BACM cases treated previously. We compared IA-BACM cases with influenza cases from the German virologic sentinel surveillance system for influenza. RESULTS: We investigated 219 children with IA-BACM. They coincided with the curve of influenza B of the German virologic sentinel surveillance system for influenza. Median age was 7 years, 74% (160/216) of cases were male, median time between the onset of fever and onset of BACM-symptoms was 3 days lasting for a median of 4 days. Almost half of the affected children had presented at hospitals. One case with beginning renal impairment occurred, but the patient recovered completely. Most reporting physicians had not seen BACM-patients previously. Multivariable analysis showed IA-BACM's strong association with influenza B, male sex, and age between 6 and 9 years. CONCLUSIONS: Influenza B caused a large BACM outbreak in Germany. Onset of BACM symptoms followed shortly after the onset of influenza symptoms. The course of this disease was almost exclusively mild and self-limiting. Diagnosis of this rare but distinct clinical entity by the alert physician can spare the patient potentially unneeded invasive testing and hospital admission.

Characteristics and risk factors for symptomatic Giardia lamblia infections in Germany.

BACKGROUND: In developed countries, giardiasis is considered a travel related disease. However, routine surveillance data from Germany indicate that >50% of infections were acquired indigenously. We studied the epidemiological characteristics of symptomatic Giardia infections acquired in Germany and abroad, and verified the proportion of cases acquired in Germany in order to investigate risk factors for sporadic autochthonous Giardia infections. METHODS: We identified Giardia cases notified by 41 local health authorities between February 2007 and January 2008 and interviewed them on their clinical symptoms, underlying morbidities, travel abroad and potential risk factors for the disease. We conducted a case-control-study including laboratory-confirmed (microscopy or antigen-test) autochthonous Giardia cases with clinical manifestations (diarrhoea, cramps, bloating) and randomly selected controls from the local population registry matched by county of residence and age-group (0-5, 6-19, > or =20 years). Secondary cases, controls with diarrhoea and persons who had travelled outside Germany in the three weeks prior to disease onset (exposure period) were excluded. We calculated adjusted odds ratios (aOR) with 95% confidence intervals (CI) using conditional logistic regression. RESULTS: Of 273 interviewed cases, 131 (48%) had not travelled abroad during the defined exposure period. Of these 131, 85 (65%) were male, 68 (54%) were living in communities with >100,000 inhabitants and 107 (83%) were aged 20 years or older. We included 120 cases and 240 controls in the case-control study. Cases were more likely to be male (aOR 2.5 CI 1.4-4.4), immunocompromised (aOR 15.3 CI 1.8-127) and daily consumers of green salad (aOR 2.9 CI 1.2-7.2). Contact with animals (pets/farm animals) and exposure to surface water (swimming/water sports) were not associated with symptomatic disease. CONCLUSIONS: A substantial proportion of Giardia lamblia cases in Germany are indigenously acquired. Symptomatic cases are significantly more likely to be immunocompromised than control persons from the general population. Physicians should consider Giardia infections among patients with no recent history of travel abroad, particularly if they have immune deficiencies. Green salads may be an important vehicle of infection. Information campaigns highlighting this food-borne risk should emphasise the risk to persons with immune deficiencies.

[Intervention epidemiology training programs in Germany and Europe. An investment in our future]. / Ausbildungsprogramme für angewandte Epidemiologie in Deutschland und Europa. Eine lohnende Investition für die Zukunft.

Outbreaks of infectious diseases such as SARS and influenza can have a profound impact on society. Therefore, training epidemiologists in infectious diseases control is of crucial importance. The German Postgraduate training in Applied Epidemiology (PAE) at the Robert Koch Institute (RKI) and the European Programme for Intervention Epidemiology Training (EPIET) are striving to meet these challenges. Currently, 27 and 12 persons of German origin have joined PAE and EPIET, respectively. A total of 17 out of the 36 alumni started working at the RKI, regional or local German health authorities after completing their training. Since 2006, the number of yearly admitted fellows increased from 3 to 6 in PAE, and 9 to 19 in EPIET and 5 state health departments have been added as training sites. The collaboration between EPIET and PAE has been strengthened and diversified in recent years. Alumni of these programs will play a key role in the control of infectious diseases in Germany and Europe.

Underreporting of human alveolar echinococcosis, Germany.

We estimated the total number of human alveolar echinococcosis cases in Germany from 2003 through 2005 using the multiple source capture-recapture method. We found a 3-fold higher incidence of the disease than that shown by national surveillance data. We propose a revision of the reporting system to increase case ascertainment.

Changing epidemiology of human brucellosis, Germany, 1962-2005.

Trends in the epidemiology of human brucellosis in Germany were investigated by analyzing national surveillance data (1962-2005) complemented by a questionnaire-based survey (1995-2000). After a steady decrease in brucellosis incidence from 1962 to the 1980s, a persistent number of cases has been reported in recent years, with the highest incidence in Turkish immigrants (0.3/100,000 Turks vs. 0.01/100,000 in the German population; incidence rate ratio 29). Among cases with reported exposure risks, 59% were related to the consumption of unpasteurized cheese from brucellosis-endemic countries. The mean diagnostic delay was 2.5 months. Case fatality rates increased from 0.4% (1978-1981) to a maximum of 6.5% (1998-2001). The epidemiology of brucellosis in Germany has evolved from an endemic occupational disease among the German population into a travel-associated foodborne zoonosis, primarily affecting Turkish immigrants. Prolonged diagnostic delays and high case fatality call for targeted public health measures.

Prevention of viral hepatitis in the Nordic countries and Germany.

The Viral Hepatitis Prevention Board (VHPB) convened a meeting of international experts from the public and private sectors in the Nordic countries and Germany, in order to review the epidemiological situation, the surveillance systems for infectious diseases, the immunization programmes and policy, and the monitoring of adverse events after hepatitis vaccination in those countries, to evaluate prevention and control measures, and to identify the issues that arose and the lessons learnt. Considerable progress has been made in the past decades in the prevention and control of viral hepatitis in the respective countries. Vaccination programmes have been set up, blood products' safety has significantly been improved, and outbreak investigations remain the basis for the implementation of control measures. However, additional work remains to be done. Awareness of viral hepatitis among the public and professionals should further be raised, and more political support is needed regarding the value of prevention efforts and vaccination programmes.

Leptospirosis in Germany, 1962-2003.

Epidemiologic trends of human leptospirosis in Germany were investigated by analyzing national surveillance data from 1962 to 2003 and by conducting a questionnaire-based survey from 1997 to 2000. After a steady decrease of leptospirosis incidence from 1962 to 1997, surveillance data indicate an increase in disease incidence to 0.06 per 100,000 (1998-2003). Of 102 laboratory-confirmed cases in humans from 1997 to 2000, 30% were related to occupational exposures. Recreational exposures were reported in 30% (including traveling abroad in 16%), whereas residential exposure accounted for 37% of the cases. Direct contact with animals, mostly rats and dogs, was observed in 31% of the cases. We conclude that recent changes in transmission patterns of leptospirosis, partially caused by an expanding rat population and the resurgence of canine leptospirosis, may facilitate the spread of the disease in temperate countries like Germany. Preventive measures should be adapted to the changing epidemiology of leptospirosis.

Salmonella agona outbreak from contaminated aniseed, Germany.

A nationwide outbreak of Salmonella Agona caused by aniseed-containing herbal tea occurred from October 2002 through July 2003 among infants in Germany. Consumers should adhere strictly to brewing instructions, although in exceptional cases this precaution may not be protective, particularly when preparing tea for vulnerable age groups.