Challenges in Infection Epidemiology: On the Underreporting of Norovirus Gastroenteritis Cases in Germany.

It is commonly accepted that the number of officially reported incidences of norovirus (NoV) according to the German Protection against Infection Act (Infektionsschutzgesetz) does not reflect the 'true' incidence of NoV in Germany. This study aims to reveal the reasons for the underreporting of NoV cases by comparing secondary data. METHODS: NoV incidence (cases per 100,000 reference persons) in the age group 18-65 was derived from register data of four different sources in the German public health system (2011-2015): Statutory health insurance in the federal state of Lower Saxony (AOK; in- and outpatient cases), the Research Institute of Ambulatory Health Care in Germany (ZI; outpatient cases), the German Federal Statistical Office (inpatient cases; DESTATIS), and the Robert Koch Institute (RKI SurvStat; health reporting data). RESULTS: the incidence derived from the AOK in Lower Saxony varied between 49 and 66 NoV cases per 100,000 persons and was thus lower than at the federal level. Incidences of all inpatient and outpatient data were lower than the incidence according to the RKI in the last 2-3 years of the observation period. CONCLUSIONS: the disagreement between NoV incidences calculated from secondary inpatient and outpatient data and the respective numbers published by the RKI can be regarded as an indication that not all NoV cases were reported to public health authorities. This might be due to missed cases during the notification procedure or misclassification of gastroenteritis cases by general practitioners. Considering the limitations associated with analyzing secondary data, the appropriateness of these assumptions should be verified in future studies.

["Good dying"--definition and current state of research]. / Was ist "gutes Sterben"? Begriffsklärung und Stand der Forschung.

The advances of modern medicine did not only result in prolongation of life expectancy, but also led to a shift from dying at home to dying in public institutions. In western countries most people die at advanced age in medical facilities. Hence, the question regarding the conditions, which should be provided by society and especially medicine, to allow terminally ill people to experience "good dying" is substantial. For this purpose, an examination of patients', family members' and health care providers' understanding of the term " good dying" is required. The present paper aims at shedding light on the term "good dying" and to summarize the current state of research. Therefore, the attributes of "good dying" will be described from the perspectives of patients, family members and health care providers, which are discussed and examined in current medical-sociological research. These attributes can be illustrated on three dimensions: Quality of life at the end of life (e. g. pain relief, mental well-being), quality of dying (e. g. avoiding prolonged dying, autonomy, presence of relatives) and quality of health care at the end of life (e. g. patient-oriented health care, positive communication between health care providers and patients, availability of guidelines). Although the attributes of "good dying" are described in detail in the existing literature, further studies have to clarify the relevance and impact of these attributes as predictors of "good dying".

Mefloquine at the crossroads? Implications for malaria chemoprophylaxis in Europe.

Since its introduction to the market in 1985, mefloquine has been used for malaria chemoprophylaxis by more than 35 million travellers. In Europe, in 2014, the European Medicines Agency (EMA) issued recommendations on strengthened warnings, prescribing checklists and updates to the product information of mefloquine. Some malaria prevention advisors question the scientific basis for the restrictions and suggest that this cost-effective, anti-malarial drug will be displaced as a first-line anti-malaria medication with the result that vulnerable groups such as VFR and long-term travellers, pregnant travellers and young children are left without a suitable alternative chemoprophylaxis. This commentary looks at the current position of mefloquine prescribing and the rationale of the new EMA recommendations and restrictions. It also describes the new recommendations for malaria prophylaxis that have been adapted by Switzerland, Germany, Austria and Italy where chemoprophylaxis use is restricted to high-risk malaria-endemic areas.

[Problems of evaluating regional integrated care using the example of "Gesundes Kinzigtal Integrated Care"]. / Probleme der Evaluation einer regionalen integrierten Vollversorgung am Beispiel "Gesundes Kinzigtal"

"Gesundes Kinzigtal Integrated Care" (GKIC) is one of the few population-based integrated care systems in Germany. The external evaluation of GKIC has a modular design and is coordinated by the Department of Medical Sociology of Freiburg University. In this article we will outline the different evaluation modules and address typical problems arising in the evaluation of regional integrated health care systems. One of these problems is the small size of the intervention population in a recently established pilot care system which makes the use of epidemiologic measures (such as incidence figures) difficult. Total population surveys could alleviate this problem, but when the same intervention population is questioned repeatedly for different evaluation modules, the danger of 'over-surveying' arises. This may lead to decreasing participation in further studies. These problems may be managed by using short survey instruments, by conducting surveys successively (not simultaneously) using time shifts, and by analysing claims data from health insurers. Another problem in the evaluation of comparably small systems of care is how to attribute outcomes (effects) to certain health promotion or disease management programmes: Since participants usually take part in more than one programme, the intervention effect is contaminated by multiple programme effects. These will have to be adjusted for in the final evaluation of the data. Finally, randomised controlled study (RCT) designs frequently cannot be used in the evaluation of a region-wide pilot intervention, so the evidence generated by such a (non-randomised) study is weaker than the evidence generated by an RCT.