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.

Diagnostic accuracy of two pressure ulcer risk scales and a generic nursing assessment tool. A psychometric comparison.

AIM: Comparison of the diagnostic accuracy of two pressure ulcer risk assessment scales and one generic nursing assessment tool. BACKGROUND: Guidelines for pressure ulcer prevention recommend an initial risk screening of all patients, followed by appropriate nursing interventions. Additionally, personal and financial resources have to be allocated carefully to avoid excessive or too little treatment. Risk assessments should be accurate and applicable, and some studies showed that generic nursing tools also provide specific information for nursing diagnoses, like risk for pressure ulcer. DESIGN: Cross sectional observational study. METHODS: A total of 1053 adult patients of a university hospital in Germany were investigated. For each patient, the Braden Scale, the Waterlow Scale and the Care Dependency Scale were completed. A skin inspection was conducted by trained nurses. Correlations between the three scales and the mean values of each pressure ulcer risk assessment scales for each Care Dependency Scale value were calculated. To determine the association between susceptibility to pressure ulcer and observed pressure ulcer, the area under the curve was calculated. RESULTS: There was a higher correlation between the Braden Scale and the Care Dependency Scale (r = 0.82) than between the two pressure ulcer risk assessment scales (-0.65). The highest area under the curve was reached by the Braden Scale (0.86), followed by the Care Dependency Scale (0.83) and the Waterlow Scale (0.81). Only the Braden Scale (cut-off 18) and the Care Dependency Scale (cut-off 65) reached the psychometric requirements of at least 70% sensitivity and 70% specificity. CONCLUSIONS: The Care Dependency Scale could be used for both a general nursing assessment and as a screening tool for risk for pressure ulcers. The Braden Scale showed the highest association with the occurrence of pressure ulcer. RELEVANCE TO CLINICAL PRACTICE: The Care Dependency Scale is a useful screening tool to identify patients at risk for pressure ulcers. Nursing assessment activities might be reduced by using a generic nursing assessment tool also for specific risk screening.

[Pressure ulcer prevalence in Germany: results of a cross-sectional study in 2006]. / Dekubitusprävalenz in Deutschland: Ergebnisse einer Querschnittsstudie 2006.

In April 2006 the sixth study to survey the prevalence of nursing-related health problems in German hospitals and nursing homes was conducted. In total 7107 persons partcipated in this study. The pressure ulcer prevalence was calculated for the participants who were assessed to be at pressure ulcer risk. In nursing homes the prevalence was 8.3 percent, in hospitals 15.1 percent of patients at risk showed at least one pressure ulcer. Although the proportion of persons at risk did not alter during the last five years, the prevalence decreased within this time. Therefore one can assume that the quality of pressure ulcer prevention and therapy has been improved.

[Pressure ulcer prevention in German hospitals. An analysis of nursing practice with regard to guideline recommendations]. / Dekubitusprophylaxe in deutschen Kliniken. Eine Analyse der Pflegepraxis bezogen auf die Empfehlungen des Expertenstandards.

UNLABELLED: Pressure ulcers are still a common health problem. Prevention and therapy of pressure ulcers require extensive nursing resources. Based on epidemiological data the use of preventive interventions and devices in hospital patients at risk was analysed. One object of this study was to compare the nursing practice with the recommendations given by a national practice guideline about pressure ulcer prevention by the German Network for Quality Development in Nursing (DNQP). Since 2002 each year a study has been conducted in order to investigate the prevalence of pressure ulcers in German hospitals. For the present study data of 9159 patients at pressure ulcer risk collected in three years (from 2002 to 2004) were analysed. RESULTS: In the course of the investigated period interventions and devices were increasingly adjusted to the recommendations of the guideline. This trend appears to be slightly, but it is noticeable. The number of process requirements realised for each patient increased particularly if patients showed a high risk or a pressure ulcer was already present. To improve the quality of care preferably all process criteria according to the guideline should be considered if preventive measures are planned.

Treatment of pressure ulcers: results of a study comparing evidence and practice.

Pressure ulcers remain prevalent in hospitals and nursing homes despite the availability of evidence-based guidelines for prevention and care. To evaluate the level of evidence-based literature and its application in pressure ulcer treatment, a search was conducted of relevant English and German articles published between 1994 and 2002 using the key terms decubitus ulcer and its synonyms in different combinations with therapy, wound management, and specific wound treatment terms. Results were compared to wound dressing use data obtained from two pressure ulcer prevalence surveys conducted in 51 hospitals and 15 nursing homes in Germany in 2001 and 2002 (N = 11,584). Dressing usage evidence levels were reviewed and reported usage was classified as consistent or not consistent with existing guidelines or as evidence base unknown. Pressure ulcer prevalence rates ranged from 10.6% to 13.2% and the majority of pressure ulcers (60%) were Grade 1. In nursing homes, dressing selection was consistent with current evidence in 6.8% of Grade 1 and 27.8% of Grade 2 ulcers. In acute care facilities, dressing selection in 2001 and 2002 was consistent with current evidence in 21.6% and 38.5%, respectively, of Grade 1 ulcers and in 40.2% and 51.5%, respectively, of Grade 2 ulcers. Although strong evidence exists to support the use of dressings that facilitate moist wound healing, barely half of the grade 3 and grade 4 ulcers in all care settings received this treatment. While dressing classification limitations restricted the ability to analyze all treatment methods used, findings suggest that clinician knowledge deficits regarding evidence-based treatments remain. The literature review results also indicate the level of evidence for many practice recommendations remains low. Studies to increase evidence levels of pressure ulcer prevention and treatment as well as programs to improve awareness and implementation of current evidence-based guidelines are needed.