Ten years of weekly epidemiological teleconference (EpiLag) - an effective and time-efficient tool for infectious disease event information, Germany, 2009-2018.

In 2009, the Robert Koch Institute (RKI) and the 16 German federal state public health authorities (PHAs) established a weekly epidemiological teleconference (EpiLag) to discuss infectious disease (ID) events and foster horizontal and vertical information exchange. We present the procedure, discussed ID topics and evaluation results of EpiLag after 10 years. We analysed attendance, duration of EpiLag and the frequency of reported events. Participants (RKI and state PHA) were surveyed regarding their satisfaction with logistics, contents and usefulness of EpiLag (Likert scales). Between 2009 and 2018, RKI hosted 484 EpiLag conferences with a mean duration of 25 min (range: 4-60) and high participation (range: 9-16; mean: 15 PHAs). Overall, 2975 ID events (39% international, 9% national and 52% subnational) were presented (mean: 6.1 per EpiLag), most frequently on measles (18%), salmonellosis (8%) and influenza (5%). All responding participants (14/16 PHAs and 9/9 at RKI) were satisfied with the EpiLag's organization and minutes and deemed EpiLag useful for an overview and information distribution on ID events relevant to Germany. EpiLag is time efficient, easily applicable and useful for a low-threshold event communication. It supports PHAs in crises and strengthens the network of surveillance stakeholders. We recommend its implementation to other countries or sectors.

How specific are risk factors for headache in adolescents? Results from a cross-sectional study in Germany.

BACKGROUND: The identified preventable risk factors for primary headache in adolescents are smoking; consumption of coffee or alcoholic mixed drinks; physical inactivity; muscle pain in the head, neck, or shoulder region; and chronic stress. OBJECTIVE: To investigate the interrelation of headache with other health complaints and the specificity of the above-mentioned risk factors for headache in adolescents. METHODS: A total of 1,260 students (grades 10 and 11) filled in questionnaires on headache, dietary, and lifestyle factors. The type of headache and health complaints such as dizziness, abdominal pain, musculoskeletal pains, symptoms of possible fatigue syndrome, and psychic complaints were assessed. RESULTS: Isolated headache was found in 18% of the headache sufferers; most frequently isolated tension-type headache (78.2%). Only among adolescents with a combination of headache (mainly migraine) and other health complaints, significant associations for almost all analyzed risk factors were found. The strength of the associations with the considered risk factors was very similar in all three analyzed strata except for considerably lower odds ratios for isolated headache. CONCLUSION: All analyzed risk factors are nonspecific for headache in adolescents because they also increase the risk for other health complaints. Interventions, therefore, should consider a holistic approach focusing not only on headache but also on a broader spectrum of health complaints.

Prevention of headache in adolescents: population-attributable risk fraction for risk factors amenable to intervention.

INTRODUCTION: Several risk factors for headache have been identified, some of which are potentially amenable to interventions. The potential effect of such interventions can be predicted by the population-attributable risk fraction (PARF). We assessed PARFs of the the following risk factors: neck muscle pain, chronic stress, alcohol consumption, smoking, coffee consumption, and physical inactivity. We studied the maximal possible effect achievable by avoidance of these risk factors. METHODS: Two approaches to estimate PARFs are compared, which assess their cumulative and individual impact of risk factors by age: the Levin formula and the average attributable fraction. RESULTS: The overall impact for removal of all six risk factors amounts to 19.7% for the average attributable fraction. Neck tension and consumption of alcohol ranked as the strongest population-attributable risk factor for any headache. The potential impact for migraine was considerably higher (43.8%). With increasing age, the overall impact of risk factors on headache increases by 18.9%. CONCLUSION: Based on the estimations of the most appropriate approach, up to 20% of headaches in general and up to 43% of migraine in adolescents might be preventable by removing risk factors amenable to intervention, with increasing proportions by age.

Self-reported muscle pain in adolescents with migraine and tension-type headache.

AIM: To identify possible associations between muscular pain and headache in adolescents in a large population-based sample. METHODS: Grammar school students were invited to fill in a questionnaire on headache and associated lifestyle factors. Headache was classified according to the German version of the International Classification of Headache Disorders (2nd edition). Muscular pain was assessed via denoting affected areas in schematic drawings of a body and via provoked muscular pain on controlled movements of head, neck and shoulder regions. RESULTS: Prevalence of any headache within the previous 6 months exceeded 80%. In all subjects muscular pain or pain on movement was most prominent in the neck and shoulder region, ranging from 9% to 27% in the non-headache population to up to 63% for individuals with migraine or mixed migraine and tension-type headache (TTH). Frequency of muscular pain increased significantly with growing chronicity of TTH. INTERPRETATION: A strong association between muscle pain in the neck/shoulder region and headache was observed, pointing to the importance of muscular pain for headache in adolescents. Also, in this age group muscular pain appears to be of particular importance in chronic TTH and - unexpectedly - in migraine, which is the most important new finding in our study.

Identified risk factors and adolescents' beliefs about triggers for headaches: results from a cross-sectional study.

Although there are few studies on adolescents' beliefs about triggers of headache, none of these compared the associations between perceived and observed triggers. This study aimed at comparing the prevalence of self-perceived and observed risk factors for headache among adolescents. Adolescents from the 10th and 11th grades of high schools answered questionnaires on their headaches and on potential risk factors regarding lifestyle, stress and muscle pain. Individuals reporting to have experienced headache in the preceding 6 months were asked to report what they believed to cause their headache (self-perceived triggers). 1,047 (83 %) of 1,260 adolescents reported headaches. Stress, lack of sleep and too much school work were the most frequently reported self-perceived triggers of headache; in contrast the statistical analysis identified alcohol and coffee consumption, smoking, neck pain, stress and physical inactivity as risk factors for headache. Among individuals with headache, 48 % believed that stress might trigger their headaches, while increased stress scores were only observed in 23 %. In contrast, while 7, 4, 0.3 and 0 % of individuals reporting headache considered consumption of too much alcohol, neck pain, physical inactivity and consumption of coffee might trigger their headache, 56, 51, 36 and 14 %, respectively, were exposed to these risk factors. The prevalence of self-perceived triggers of headache does not correspond to the prevalence of identified risk factors for headaches. While the role of stress was overestimated, the high prevalence of the other confirmed risk factors in adolescents with headache suggests potential for prevention by increasing awareness for these risk factors and appropriate interventions.

Associations between stress and migraine and tension-type headache: results from a school-based study in adolescents from grammar schools in Germany.

INTRODUCTION: Stress is considered the major contributor to migraine and tension-type headache in adolescents. Previous studies have focused on general stressors, whereas the aim of the present study was to investigate associations between individuals' stressful experiences and different types of headache. METHODS: Adolescents from 10th and 11th grades of grammar schools filled in questionnaires. Stressful experiences were measured with the Trier Inventory of Chronic Stress. Type of headache was classified according to the International Classification of Headache Disorders. Linear regressions, adjusted for sex and grade, were calculated to estimate differences in stress scores that can be attributed to migraine, tension-type headache or miscellaneous headache. RESULTS: A total of 1260 questionnaires were analysed. Tension-type headache, migraine and co-existing migraine plus tension-type headache were found in 48.7%, 10.2% and 19.8% of the participants. In subjects with migraine or co-existing migraine plus tension-type headache, high increases in stress scores were found in all investigated dimensions, whereas much weaker and inconsistent associations were found in subjects with tension-type headache only. CONCLUSIONS: The characteristic of migraine is more associated with stressful experiences than this is the case for tension-type headache. This suggests that adolescent migraine patients might especially benefit from behavioural interventions regarding stress.

Quality of life in adolescents with headache: results from a population-based survey.

The aim of the investigation was to study the impact of headache on quality of life (QOL) in adolescents in a population-based sample (N = 1047, aged between 13 and 17 years). QOL was assessed using the KINDL-R (Revidierter Kinder Lebensqualitätsfragebogen) questionnaire with its six dimensions. In order to assess potential differences in the impact on QOL according to the type of headache, a stratified analysis was performed. QOL differences compared to the 'no headache' group are presented with adjustment for socio-demographic confounders. Headache at least once per month was reported in 48% of the adolescents and accounted for a small but significant reduction of 2.5 points in the total KINDL-R score, which was mainly caused by a reduction in physical wellbeing by 6.8 points. Adolescents with migraine reported higher reductions in physical wellbeing and total QOL than subjects with tension-type headache (TTH). The size of the reduction in QOL scores was small but similar to that observed for other chronic conditions in adolescents. Headache prevention programs might therefore have an impact on QOL in adolescents.

The association between use of electronic media and prevalence of headache in adolescents: results from a population-based cross-sectional study.

BACKGROUND: Use of electronic media, i.e. mobile phones, computers, television, game consoles or listening to music, is very common, especially amongst adolescents. There is currently a debate about whether frequent use of these media might have adverse effects on health, especially on headaches, which are among the most-reported health complaints in adolescents. The aim of the present study was to assess associations between frequent use of electronic media and the prevalence of different types of headache in adolescents. METHODS: Data were derived from a population-based sample (n = 1,025, ages 13-17 years). Type of headache (i.e. migraine, tension-type headache, unclassifiable headache) was ascertained by standardized questionnaires for subjects reporting headache episodes at least once per month during the last six months. Duration of electronic media use was assessed during personal interviews. Associations were estimated with logistic regression models adjusted for age group, sex, family condition and socio-economic status. RESULTS: Most of the adolescents used computers (85%), watched television (90%) or listened to music (90%) daily, otherwise only 23% of the participants used their mobile phones and only 25% played with game consoles on a daily basis. A statistically significant association between listening to music and any headache (odds ratio 1.8; 95% confidence interval 1.1-3.1 for 30 minutes per day, 2.1; 1.2-3.7 for 1 to 2 hours per day; 2.0; 1.2-3.5 for 3 hours and longer listening to music per day) was observed. When stratifying for type of headache, no statistically significant association was seen. CONCLUSIONS: Apart from an association between listening to music on a daily basis and overall headache, no consistent associations between the use of electronic media and different types of headache were observed.

Associations of diet and lifestyle with headache in high-school students: results from a cross-sectional study.

BACKGROUND: Diet and lifestyle are seen as factors which influence headache in adults. However, population-based studies on this issue in adolescents are rare. OBJECTIVE: Aim of the present study was to investigate associations between diet and lifestyle factors and different types of headache, ie, migraine and tension-type headache (TTH) in adolescents. METHODS: A total of 1260 adolescents from the 10th and 11th grades of high schools filled in questionnaires on intake of meals, coffee, nonalcoholic and alcoholic drinks, smoking, and physical activity. Type of headache was classified according to the International Classification of Headache Disorders - 2nd edition. Multiple logistic regression models, adjusted for sex and grade, were calculated. RESULTS: High consumption of cocktails (odds ratio = 3.4; 95% confidence interval 1.9-6.0) and coffee (2.4; 1.3-4.7), smoking (2.7; 1.4-5.1), and lack of physical activity (2.2; 1.3-3.7) were significantly associated with migraine plus TTH episodes, consumption of coffee and physical inactivity particularly with migraine (3.4; 1.6-7.0 and 4.2; 2.2-7.9, respectively) and physical inactivity with TTH (1.7; 1.1-2.7). Skipping of meals or insufficient fluid intake were not associated with any type of headache. CONCLUSIONS: Adolescents with any type of headache might benefit from regular physical activity and low consumption of alcoholic drinks, while for migraine patients a low consumption of coffee should additionally be recommended. Intervention studies are warranted to assess whether psycho-educational programs conferring knowledge of these associations will influence headache-triggering behavior and headache in adolescents.

Higher prevalence of psychopathological symptoms in adolescents with headache. A population-based cross-sectional study.

BACKGROUND: Headache is commonly voiced by adolescents and is known to be associated with reduced quality of life. Otherwise, there are only limited data regarding associations between different types of headache and psychopathological symptoms in adolescents. OBJECTIVES: Aim of the present study in adolescents was to assess the impact of headache on psychopathological symptoms and whether these differ between types of headache. METHODS: Data were derived from a population-based sample (n = 1047, ages 13-17 years). Type of headache (ie, migraine, tension-type headache, miscellaneous headache) was ascertained for subjects reporting headache episodes at least once per month. Psychopathological symptoms were assessed with the Strengths and Difficulties Questionnaire. The following dimensions were taken into account: emotional symptoms, conduct problems, hyperactivity/inattention, peer problems (these 4 add to the total difficulties score), and prosocial behavior. Associations were estimated with logistic regression models with adjustment for age group, sex, and family situation. RESULTS: Headache at least once per month was reported by 47.8% of the adolescents. Subjects with any headache were found to be at higher risk for emotional symptoms (odds ratio 1.5; 95% confidence interval 1.0-2.2) and hyperactivity/inattention (1.4; 1.0-1.9), resulting in a higher total difficulties score (1.6; 1.1-2.4). While the risk for psychopathological symptoms was not significantly increased in subjects with tension-type headache compared with subjects without headache, significant associations with emotional symptoms were found in subjects with migraine (2.9; 1.3-6.2; total difficulties score: 3.1; 1.4-6.8). Miscellaneous headache was associated with a broad spectrum of psychopathological symptoms: emotional symptoms (1.8; 1.0-3.3), conduct problems (1.6; 1.0-2.6), hyperactivity/inattention (1.9; 1.2-3.1), total difficulties score (2.7; 1.6-5.6). CONCLUSION: Previously reported associations between headache and psychopathological symptoms in adolescents could be confirmed, but might vary with type of headache. As psychopathological symptoms may be a precursor for manifest psychiatric disorders, adolescents particularly with migraine and miscellaneous headache appear to be a vulnerable population.

Invasive Haemophilus influenzae infections in Germany: impact of non-type b serotypes in the post-vaccine era.

BACKGROUND: Haemophilus influenzae type b (Hib) vaccination led to a significant decrease in invasive bacterial infections in children. The aim of this study was to assess a potential shift to more non-type b invasive infections in a population with high Hib vaccination coverage and to compare the burden of suffering between children with Hib, capsulated non-b and non-capsulated Hi infections. METHODS: Cases with confirmed invasive Hi infections were ascertained through two independent nationwide active surveillance systems in 1998-2005. Information on possible predisposing conditions and clinical information was available from 2001 onwards. RESULTS: The total number of reported non-type b Hi cases varied between 10 cases in 1998, 27 in 2000 and 14 in 2005. In each year, non-capsulated serotypes outnumbered capsulated non-type b ones. 192 cases were detected in 2001-2005, more than one half was non-type b and 88% of the non-type b cases were non-capsulated. For cases with Hib/capsulated non-type b infections the most common clinical presentation was meningitis (67% each); 89%/78% had no potential predisposing condition, 75%/72% completely recovered from disease and 6% (each) died. In contrast, meningitis was diagnosed in 34% of the non-capsulated Hi infections, septicaemia in 28% and pneumonia 21%; 62% had no potential predisposing condition, 83% completely recovered and 3% died. CONCLUSION: There was no increase in non-type b Hi invasive infections during 8 years of active surveillance in Germany. Invasive disease due to non-type b Hi is not confined to children with risk factors. In patients with capsulated non-type b Hi infections the proportion of meningitis cases is similar to Hib, but double as high as in non-capsulated Hi.

Association between peer relationship problems and childhood overweight/obesity.

AIMS: To assess the association between peer relationship problems and childhood overweight and obesity. METHODS: Data on 4718 preschool children were obtained at the obligatory school entry health examination in Bavaria. Parentally reported peer relationship problems ('normal', 'borderline' or 'abnormal') were assessed from the Strengths and Difficulties Questionnaire. Overweight and obesity were defined according to age- and gender-specific BMI cut-off points. Multivariate logistic regression analysis was performed to control potential confounders. RESULTS: The prevalence of overweight and obesity was higher among children with 'borderline' or 'abnormal' peer relationship problems compared to 'normal' children. The association of 'abnormal' peer relationship problems was still significant in the final logistic regression model for girls [odds ratio (OR) for overweight 2.0; 95% confidence interval (CI): 1.4-3.0; OR for obesity 2.6; 95% CI: 1.3-5.0]. Among boys the adjusted odds ratio were lower and no longer significant. CONCLUSION: The significantly increased prevalence of overweight and obesity among preschool children with peer relationship problems could not be explained by confounding. It seems evident that there is a relevant co-morbidity of peer relationship problems and obesity in pre-school children pointing to the need of interventions focusing on both physical as well as psychosocial health.

Surveillance for rare infectious diseases: is one passive data source enough for Haemophilus influenzae?

BACKGROUND: The completeness of a compulsory reporting system of systemic Haemophilus influenzae infections in children in Germany is studied by means of cross-linking registry data from three sources and applying capture-recapture methods. METHODS: Cases were collected for the years 2001-05 by three national data sources: a passive administration registry (SurvNet@RKI), an active hospital surveillance system and an active laboratory surveillance system. The case definition required cultural detection of H. influenzae in blood or cerebrospinal fluid. Linkage was carried out by month and year of birth, sex, geographical region and date of disease onset. Capture-recapture models were used to estimate the incidence of invasive H. influenzae infections. RESULTS: SurvNet@RKI reported 113 H. influenzae and 38 H. influenzae type b (Hib) cases, compared to a total of 231 and 68 cases, respectively, reported by all three sources combined. Best-fitting 3-source capture-recapture estimations amounts to 258 (95% confidence interval: 247-276) H. influenzae and 71 (69-74) Hib cases. SurvNet@RKI data depicted a similar decrease in annual H. influenzae cases as the capture-recapture estimates but failed to detect the underlying decrease in Hib cases which was observed in the capture-recapture estimates due to a considerable annual variability of ascertainment of serotyped cases in SurvNet@RKI ranging from 14% to 69%. CONCLUSIONS: Because of small variability of ascertainment, the compulsory passive reporting system depicted trends in H. influenzae incidence, although less than half of the cases were ascertained. However, time trend in Hib cases could not be depicted, because of highly variable serotyping proportions.

Risk Factors for Sporadic Non-Pregnancy Associated Listeriosis in Germany-Immunocompromised Patients and Frequently Consumed Ready-To-Eat Products.

Non-pregnancy associated (N-PA) listeriosis, caused by Listeria monocytogenes, is a rare but severe disease, and is predominantly food-borne. Most cases appear sporadic and their infection vehicle remains unknown. Incidence has increased since 2008 in Germany. We aimed to identify underlying conditions and foods associated with sporadic N-PA listeriosis in Germany. We performed a nationwide case-control study from March 2012-December 2013. Cases were sporadic N-PA listeriosis patients notified to public health. Control subjects were age (40-65 years, 66-75 years, ≥ 76 years) frequency-matched persons from a nationwide random telephone sample. A structured questionnaire collected information on underlying diseases, therapies and >60 food items. We conducted multivariable logistic regression analysis, adjusting for host factors identified by causal diagram theory, and calculated population attributable fractions. We enrolled 109 cases and 1982 controls. Cases' median age was 69 years, 55% were male, 44% received immunosuppressive therapy within 3 months prior to illness onset; a further 28% had at least one immunocompromising disease. In multivariable analysis, immunosuppressive therapy (OR 8.8, 95%CI 4.9-15.6), immunocompromising disease (OR 2.7; 95%CI 1.4-5.2), gastric acid suppression (OR 3.0; 95%CI 1.4-6.3), the consumption of cold cooked sausages (OR 2.6; 95%CI 1.6-4.4), the preferred consumption of packaged cheese (OR 2.1; 95%CI 1.3-3.5) and pre-sliced cheese (OR 2.2; 95%CI 1.3-3.7) were significantly associated with N-PA listeriosis. These foods accounted for 59% of all cases. Typical high risk foods, e.g. cold seafood, certain types of cheeses, tended to be negatively associated with disease. In conclusion, immunosuppressive therapy and frequently consumed ready-to-eat foods are the main risk factors for sporadic N-PA listeriosis in Germany. To reduce their risk, immunocompromised persons should consume the identified foods well before the 'use-by' date. The microbiological criteria for Listeria monocytogenes in ready-to-eat foods may insufficiently protect persons who are markedly immunocompromised.

Altered cerebrovenous drainage in patients with migraine as assessed by phase-contrast magnetic resonance imaging.

OBJECTIVE: We aimed to assess whether migraine is associated with changes in the distribution of the venous drainage through primary and secondary pathways by using phase-contrast magnetic resonance imaging (MRI). METHODS: We examined 26 patients (37.3 ± 13.9 years) with recurring migraine headaches and 26 age- and gender-matched controls with no neurologic disease (37.3 ± 13.7 years) on a 3 Tesla MR scanner. A 2D time-of-flight MR-venography of the upper neck region was performed to visualize the venous vasculature. Cine-phase contrast scans with high-velocity encoding were employed to quantify arterial inflow and flow in the primary venous channels (right and left jugular veins), whereas scans with low-velocity encoding were employed to quantify flow in the secondary venous channels (epidural, vertebral, and deep cervical veins). RESULTS: Patients with migraine showed (i) a higher prevalence of dense secondary extracranial venous networks (15 vs. 2, P = 0.00002) and (ii) a significantly larger percentage of venous outflow through secondary channels (10.5% vs. 5.5%; of total cerebral blood flow, P = 0.02). This mainly included drainage through epidural, vertebral, and deep cervical veins. CONCLUSION: Migraine patients showed a significantly larger percentage of venous outflow through secondary channels. The mechanism of this alteration remains to be elucidated. Potential mechanisms include repeated release of vasoactive substances or growth factors.