Evaluation of 17 years of MERIN (Meningitis and Encephalitis register in Lower Saxony, Germany) surveillance system: participants acceptability survey, completeness and timeliness of data.

BACKGROUND: A Meningitis and Encephalitis Surveillance (MERIN) was implemented in 2003 in Lower Saxony, Germany as an alternative to acute flaccid paralyses surveillance, as the latter did not reach WHO sensitivity criteria. The system provides information on circulating enterovirus (EV) serotypes by focussing on patients with suspected aseptic meningitis, encephalitis or acute flaccid paralysis and contributes to the national surveillance in documenting polio free status. MERIN is based on voluntary participation of hospitals. Therefore, our evaluation focusses on acceptability of the system's objectives and performance, and identifying areas for improvement. METHODS: To assess acceptability, 32 contributing hospitals were invited to an online-based survey (11/2021 to 01/2022) to rate the MERIN objectives, laboratory's performance, their workload, modes of processes and communication. Ideas for improvement were collected in open fields. In addition, data completeness and timeliness of laboratory diagnostics were assessed. RESULTS: Of 32 hospitals, 21 responded (66% response rate), sending 30 questionnaires, 25 from pediatric and 5 from neurological departments. High levels of satisfaction with the communication (≥ 96%), timeliness (≥ 81%), and distribution of the results (≥ 85%) were reported, 97% of participants judged the required workload as adequate. The median proportion of eligible patients included in MERIN was 75%. Participants gave rapid and reliable diagnostic testing the highest priority (96%), while monitoring of Germany's polio-free status was rated the lowest (61%). Providing medical reports digitally as well as regular updates about circulating EV serotypes were identified as areas for improvement. Data completeness of selected variables ranged from 78.3 to 99.9%. Median time between sample collection and arrival at laboratory was 2 days [IQR 1-3], EV diagnostics via PCR took one day [IQR 0-6] and EV isolation on cell culture 11 days [IQR 10-13]. CONCLUSION: MERIN is a highly accepted surveillance system. Its quality was enhanced further by addressing the suggested improvements such as regular reports on circulating EV serotypes and facilitating digital access to laboratory results. Our results emphasise the importance of recognizing and considering participants' motivations and expectations, and addressing their priorities, even if this is not the surveillance system's main focus. This approach can be applied to surveillance systems of other non-mandatory notifiable diseases.

Recruiting controls from an online panel for a case-control study enabled a timely and reliable foodborne Salmonella outbreak investigation, Germany 2021.

We explored the feasibility, suitability, and reliability of using controls recruited among members of a non-probabilistic online panel ('panel controls') in a case-control study (CCS) to investigate a Salmonella Braenderup outbreak in Germany. For comparison, another control group was recruited via random digit dialling ('classical controls'). Panel members received questionnaires by email; classical controls were interviewed by phone. Both control groups were frequency-matched to cases by age and sex; the classical controls also by federal state. Cases and controls were queried mainly about fruit consumption since melons were the suspected infection vehicle. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CIs) using single-variable and multivariable logistic regression. The study included 32 cases, 81 panel controls and 110 classical controls. Analyses identified melons, particularly Galia melons, as the most likely infection vehicle using either control group (panel controls - aOR 12, CI 2.7-66; classical controls - aOR 55, CI 8-1100). Recruitment of panel versus classical controls required substantially less person-time (8 vs. 111 hours) and was about 10 times less expensive. We recommend this timely and reliable control recruitment method when investigating diffuse foodborne outbreaks with CCS.

Use of a non-probabilistic online panel as a control group for case-control studies to investigate food and waterborne outbreaks in Lower Saxony, Germany.

Established methods of recruiting population controls for case-control studies in infectious disease outbreak investigations are resource- and time-intensive, and are often subject to bias. The online panel have recently gained interest as an easy and timely method to select controls. We examined the feasibility, suitability and reliability of using an online panel to select controls for case-control studies as part of investigations of diffuse food and waterborne outbreaks. In January 2019, we deployed a web survey by email to the 277 members of a non-probabilistic online panel in Lower Saxony, Germany. We questioned them on basic sociodemographic characteristics and eating habits. They were frequency matched to cases on sex and age. Their food exposures were compared to those of traditionally recruited controls of four historical case-controls studies, which successfully investigated food and waterborne outbreaks. We used logistic regressions to assess the association between the food exposures and the disease (odds ratios). The use of a control panel successfully led to the identification of the food items in three of the four historical outbreak investigations, and their recruitment benefitted from increased speed and limited costs. Timely outbreak investigations would enable rapidly implementing control measures. We recommend the further evaluation of using panellists as controls in parallel case-control studies and case-panel studies.

Reemergence of Scabies Driven by Adolescents and Young Adults, Germany, 2009-2018.

To validate anecdotal evidence on scabies infestations, we analyzed inpatient and outpatient claims data in Germany. Scabies diagnoses increased 9-fold and treatment failure 4-fold during 2009-2018, driven mainly by persons 15-24 years of age. Prevention and control in young adults appear key because of these persons' high mobility and social connectivity.

[Reduce obstacles, promote health-healthcare access for undocumented migrants within a pilot project in Lower Saxony, Germany (2016-2018)]. / Hemmnisse abbauen, Gesundheit fördern ­ Die Gesundheitsversorgung von Migrierten ohne Papiere im Rahmen eines Modellprojektes in Niedersachsen, 2016­2018.

BACKGROUND: In 2014, the parliament of the federal state of Lower Saxony (Germany) implemented a three-year pilot project to reduce barriers to healthcare for undocumented migrants. For this purpose, two counselling centres (CCs) were established (Hanover and Goettingen), where undocumented migrants receive treatment vouchers for the medical treatment of acute medical issues, check-ups, and vaccination. OBJECTIVE: We assessed which medical services were used in order to identify needs and recommend specific improvements to policymakers. METHODS: We analysed CC data from the first two years after starting the project (1 February 2016-31 January 2018). We described demographic characteristics of attendees, reasons for attendance, and medical diagnoses. Additionally, we carried out explorative interviews on the subject of vaccination in one CC (February-May 2018). RESULTS: In total, 236 undocumented migrants received 698 vouchers. The number of vouchers issued increased over time: from 17/month (February-July 2016) to 44/month (August 2017-January 2018); 56% were female and 16% were younger than 18 years. Half of the women (66/132) attended for prenatal care. In 4% (9/236) of attendees vaccinations were given. Of 25 people approached for explorative interviews, 18 participated. All of them were generally open about vaccinations; 12 (67%) had already received vaccinations at some point. CONCLUSIONS: The increasing use of CCs shows the need for low-threshold healthcare access, particularly for vulnerable groups (children, pregnant women). Vaccinations were rarely performed. Strengthening vaccination literacy by providing more information to both physicians and attendees can increase vaccination uptake.

Shiga toxin-producing Escherichia coli O103:H2 outbreak in Germany after school trip to Austria due to raw cow milk, 2017 - The important role of international collaboration for outbreak investigations.

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.

Seroprevalence of Antibodies against Measles, Rubella and Varicella among Asylum Seekers Arriving in Lower Saxony, Germany, November 2014-October 2015.

The number of asylum seekers arriving in Germany has increased rapidly since 2014 and cases of vaccine-preventable diseases at reception centres were reported. Asylum seekers 12 years and older arriving in Lower Saxony were serologically screened for antibodies against measles, rubella and varicella between November 2014 and October 2015. We calculated the seroprevalence from the screening data by disease, country of origin and age group and compared them to literature-based herd immunity thresholds in order to identify immunisation gaps. In total, 23,647 specimens were included in our study. Although the vast majority of asylum seekers tested positive for antibodies against measles, rubella and varicella, the seroprevalences were not sufficient to ensure herd immunity. The seroprevalences varied substantially between countries of origin and increased with age. Immunisation of asylum seekers against measles, rubella and varicella is needed and the detailed information on seroprevalences among subgroups of asylum seekers can be used for targeted immunisations at reception centres.