Application of the screening method for estimating COVID-19 vaccine effectiveness using routine surveillance data: Germany's experience during the COVID-19 pandemic, July 2021 to March 2023.

The screening method represents a simple, quick, and practical tool for estimating vaccine effectiveness (VE) using routine disease surveillance and vaccine coverage data, even if these data cannot be linked. In Germany, where notification data, laboratory testing data, and vaccine coverage data cannot be linked due to strict data protection requirements, the screening method was used to assess COVID-19 VE continuously between July 2021 and March 2023. During this period, when Delta and Omicron variants circulated, VE estimates were produced in real-time for different age groups and clinical outcomes. Here we describe the country's overall positive experience using the screening method, including its strengths and limitations, and provide practical guidance regarding a few issues, such as case definition stringency, testing behaviour, and data stratification, that require careful consideration during data analysis and the interpretation of the results.

Inventory study on completeness of tuberculosis case notifications in Poland in 2018.

BackgroundEvaluating tuberculosis (TB) notification completeness is important for monitoring TB surveillance systems, while estimating the TB disease burden is crucial for control strategies.AimWe conducted an inventory study to assess TB reporting completeness in Poland in 2018.MethodsUsing a double-pronged inventory approach, we compared notifications of culture-positive TB cases in the National TB Register to records of diagnostic laboratories. We calculated under-reporting both with observed and capture-recapture (CRC)-estimated case numbers. We further compared the notifications by region (i.e. voivodship), sex, and age to aggregated data from hospitalised TB patients, which provided an independent estimate of reporting completeness.ResultsIn 2018, 4,075 culture-positive TB cases were notified in Poland, with 3,789 linked to laboratory records. Laboratories reported further 534 TB patients, of whom 456 were linked to notifications from 2017 or 2019. Thus, 78 (534 - 456) cases were missing in the National TB Register, yielding an observed TB under-reporting of 1.9% (78/(4,075 + 78) × 100). CRC-modelled total number of cases in 2018 was 4,176, corresponding to 2.4% ((4,176 - 4,075)/4,176 × 100) under-reporting. Based on aggregated hospitalisation data from 13 of 16 total voivodeships, under-reporting was 5.1% (3,482/(3,670 - 3,482) × 100), similar in both sexes but varying between voivodeships and age groups.ConclusionsOur results suggest that the surveillance system captures ≥ 90% of estimated TB cases in Poland; thus, the notification rate is a good proxy for the diagnosed TB incidence in Poland. Reporting delays causing discrepancies between data sources could be improved by the planned change from a paper-based to a digital reporting system.

[Evaluation of the COVID-19 vaccination after broad implementation-an interim conclusion for Germany in July 2022]. / Evaluation der COVID-19-Impfung nach breiter Anwendung ­ ein Zwischenfazit für Deutschland im Juli 2022.

Vaccines against COVID-19 have been available in Germany since December 2020. At the Robert Koch Institute (RKI), the Immunization Unit is responsible for monitoring vaccination coverage and assessment of vaccine effectiveness. This article provides an overview of the respective reporting structures, vaccination databases, and epidemiological studies established by the Immunization Unit during the COVID-19 pandemic. We describe the COVID-19 Digital Vaccination Coverage Monitoring (DIM), which provides daily updates on vaccination coverage by age group. We next describe how, based on the DIM data and COVID-19 case data, the assessment of vaccine effectiveness against different clinical endpoints (hospitalization, intensive care, death) is performed. While this method is used for a preliminary estimate of vaccine efficacy, population-based nonrandomized studies are able to provide more precise and detailed estimates under "real-world" conditions. In this context, we describe the hospital-based case-control study COViK, which is being conducted in collaboration with the Paul Ehrlich Institute (PEI). We discuss strengths and limitations of the abovementioned structures and tools. Finally, we provide an outlook on future challenges that may arise during the ongoing pandemic and during the transition phase into an endemic situation.

Targeting screening and treatment for latent tuberculosis infection towards asylum seekers from high-incidence countries - a model-based cost-effectiveness analysis.

BACKGROUND: Enhancing tuberculosis (TB) prevention and care in a post-COVID-19-pandemic phase will be essential to ensure progress towards global TB elimination. In low-burden countries, asylum seekers constitute an important high-risk group. TB frequently arises post-immigration due to the reactivation of latent TB infection (LTBI). Upon-entry screening for LTBI and TB preventive treatment (TPT) are considered worthwhile if targeted to asylum seekers from high-incidence countries who usually present with higher rates of LTBI. However, there is insufficient knowledge about optimal incidence thresholds above which introduction could be cost-effective. We aimed to estimate, among asylum seekers in Germany, the health impact and costs of upon-entry LTBI screening/TPT introduced at different thresholds of country-of-origin TB incidence. METHODS: We sampled hypothetical cohorts of 30-45 thousand asylum seekers aged 15 to 34 years expected to arrive in Germany in 2022 from cohorts of first-time applicants observed in 2017-2019. We modelled LTBI prevalence as a function of country-of-origin TB incidence fitted to data from observational studies. We then used a probabilistic decision-analytic model to estimate health-system costs and quality-adjusted life years (QALYs) under interferon gamma release assay (IGRA)-based screening for LTBI and rifampicin-based TPT (daily, 4 months). Incremental cost-effectiveness ratios (ICERs) were calculated for scenarios of introducing LTBI screening/TPT at different incidence thresholds. RESULTS: We estimated that among 15- to 34-year-old asylum seekers arriving in Germany in 2022, 17.5% (95% uncertainty interval: 14.2-21.6%) will be latently infected. Introducing LTBI screening/TPT above 250 per 100,000 country-of-origin TB incidence would gain 7.3 (2.7-14.8) QALYs at a cost of €51,000 (€18,000-€114,100) per QALY. Lowering the threshold to ≥200 would cost an incremental €53,300 (€19,100-€122,500) per additional QALY gained relative to the ≥250 threshold scenario; ICERs for the ≥150 and ≥ 100 thresholds were €55,900 (€20,200-€128,200) and €62,000 (€23,200-€142,000), respectively, using the next higher threshold as a reference, and considerably higher at thresholds below 100. CONCLUSIONS: LTBI screening and TPT among 15- to 34-year-old asylum seekers arriving in Germany could produce health benefits at reasonable additional cost (with respect to international benchmarks) if introduced at incidence thresholds ≥100. Empirical trials are needed to investigate the feasibility and effectiveness of this approach.

International tuberculosis contact-tracing notifications in Germany: analysis of national data from 2010 to 2018 and implications for efficiency.

BACKGROUND: International contact-tracing (CT) following exposure during long-distance air travel is resource-intensive, whereas evidence for risk of tuberculosis (TB) transmission during international travel is weak. In this study, we systematically analyzed the information from international requests for CT received at the national level in Germany in order to evaluate the continued utility of the current approach and to identify areas for improvement. METHODS: An anonymized archive of international CT notifications received by the Robert Koch Institute between 2010 and 2018 was searched for key parameters for data collection. A total of 31 parameters, such as characteristics of TB patients and their identified contacts, were extracted from each CT notification and collated into a dataset. Descriptive data analysis and trend analyses were performed to identify key characteristics of CT notifications, patients, and contacts over the years. RESULTS: 192 CT notifications, each corresponding to a single TB index case, were included in the study, increasing from 12 in 2010 to 41 in 2018. The majority of notifications (N = 130, 67.7%) concerned international air travel, followed by private contact (N = 39, 20.3%) and work exposure (N = 16, 8.3%). 159 (82.8%) patients had sputum smear results available, of which 147 (92.5%) were positive. Of 119 (62.0%) patients with drug susceptibility testing results, most (N = 92, 77.3%) had pan-sensitive TB, followed by 15 (12.6%) with multi-drug resistant TB. 115 (59.9%) patients had information on infectiousness, of whom 99 (86.1%) were considered infectious during the exposure period. 7 (5.3%) patients travelled on long-distance flights despite a prior diagnosis of active TB. Of the 771 contact persons, 34 (4.4%) could not be reached for CT measures due to lack of contact information. CONCLUSION: The high variability in completeness of information contained within the international CT requests emphasizes the need for international standards for reporting of CT information. With the large proportion of TB patients reported to have travelled while being infectious in our study, we feel that raising awareness among patients and health professionals to detect TB early and prevent international long-distance travel during the infectious disease phase should be a cornerstone strategy to safeguard against possible transmission during international travel.

Completeness of tuberculosis case notifications in Germany in 2013-2017: first results of an inventory study.

BACKGROUND: Evaluating the completeness of tuberculosis (TB) notification data is important for monitoring of TB surveillance systems. We conducted an inventory study to calculate TB underreporting in Germany in 2013-2017. METHODS: Acquisition of two pseudonymized case-based data sources (national TB notification data and antibiotic resistance surveillance data) was followed by two-source Capture-recapture (CRC) analysis, as case-based data from a third source was unavailable. Aggregated data on consumption of a key anti-TB drug (pyrazinamide [PZA]) was compared to an estimated need for PZA based on TB notification data to obtain an independent underreporting estimation. Additionally, notified TB incidence was compared to TB rate in an aggregated health insurance fund dataset. RESULTS: CRC and PZA-based approaches indicated that between 93 and 97% (CRC) and between 91 and 95% (PZA) of estimated cases were captured in the national TB notification data in the years 2013-2017. Insurance fund dataset did not indicate TB underreporting on the national level in 2017. CONCLUSIONS: Our results suggest that more than 90% of estimated TB cases are captured within the German TB surveillance system, and accordingly the TB notification rate is likely a good proxy of the diagnosed TB incidence rate. An increase in underreporting and discrepancies however should be further investigated.

Impact of COVID-19 immunisation on COVID-19 incidence, hospitalisations, and deaths by age group in Germany from December 2020 to October 2021.

BACKGROUND: Utilising national surveillance data, we investigated the impact of the COVID-19 immunisation campaign on COVID-19 morbidity and mortality between December/2020 and October/2021 in Germany. METHODS: We compared patterns in immunisation coverage, incidence, hospitalisations, and deaths among 12-17, 18-59, and 60+ year-olds and examined these patterns within the context of anti-pandemic measures. RESULTS: COVID-19 incidence increased in all age groups following the end of lockdown restrictions in March/2021, but as Germany experienced successive peaks in incidence, age groups with higher immunisation coverage experienced successively smaller peaks. Notwithstanding corresponding increases during periods of higher incidence, among those aged 60+ years, COVID-19 related hospitalisations and deaths declined considerably as immunisation coverage increased, despite circulation of virus variants known to cause more severe illness. CONCLUSION: Although ecological in nature, this study allows us to demonstrate clear patterns of decline in COVID-19 morbidity and mortality in Germany during the course of the immunisation campaign.

Individual and interpersonal correlates of cardiorespiratory fitness in adults - Findings from the German Health Interview and Examination Survey.

Cardiorespiratory fitness (CRF) is an established predictor of adverse health outcomes. The aim of this study is to investigate potential behavioral, interpersonal and socioeconomic correlates of CRF among men and women living in Germany using data from a population-based nationwide cross-sectional study. 1,439 men and 1,486 women aged 18-64 participated in the German Health Interview and Examination Survey (2008-2011) and completed a standardized sub-maximal cycle ergometer test. Maximal oxygen consumption ([Formula: see text]) in ml·min-1·kg-1 was estimated. Mean values of VO2max for various anthropometric, behavioral, interpersonal, and sociodemographic variables were estimated. Linear regression analyses using multiple imputations technique for missing values was performed to analyze the influence of potential correlates on CRF. Women with high alcohol consumption had higher [Formula: see text], (ß = 2.20; 95% CI 0.98 to 3.42) than women with low alcohol consumption and women with high occupational status had higher [Formula: see text] (ß = 1.83; 95% CI 0.21 to 3.44) in comparison to women with low occupational status. Among men, high fruit intake (ß = 1.52; 95% CI 0.63 to 2.40), compared to low or medium fruit intake and performing at least 2.5 hours of total PA per week (ß = 2.19; 95% CI 1.11 to 3.28), compared to less than 2.5 hours was associated with higher [Formula: see text]. Among both men and women, lower body mass index, lower waist circumference and higher levels of physical exercise were considerably associated with higher [Formula: see text]. Among women, those in higher age groups showed a considerably lower level of [Formula: see text] compared with those aged 18-24. Furthermore, mean estimated [Formula: see text] was higher among men (36.5; 95% CI 36.0 to 37.0) than among women (30.3; 95% CI 29.8 to 30.7). Despite the cross-sectional nature of the current study, we conclude that several behavioral, anthropometric, and sociodemographic factors are associated with CRF in the general adult population in Germany. These results can provide evidence to tailor prevention measures according to the needs of specific subgroups.

First-line tuberculosis drug resistance patterns and associated risk factors in Germany, 2008-2017.

BACKGROUND: Drug-resistant tuberculosis (TB), especially multidrug-resistant TB (MDR-TB), poses a threat to public health. While standard surveillance focuses on Rifampicin and/or Isoniazid resistance, little is known about other resistance patterns. This study aims to identify predominant drug resistance (DR) patterns in Germany and risk factors associated with them in order to inform diagnostic and treatment strategies. METHODS: Case-based TB surveillance data notified in Germany from 2008-2017 were utilized to investigate DR and MDR-TB patterns for Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E), and Streptomycin (S). Predominant patterns were further analyzed stratified by sex, age, country of birth, prior TB, and disease site. Multivariable logistic regression was conducted to determine risk factors associated with any resistance, MDR-TB, and complete HRZES resistance. RESULTS: 26,228 cases with complete DST results were included in the study, among which 3,324 cases had any DR (12.7%). Four patterns were predominant, representing about ¾ of all cases with any resistance (S: 814 [3.1%]; H: 768 [2.9%]; HS: 552 [2.1%]; Z: 412 [1.6%]). High proportions of S and H resistances were found among both German and foreign-born populations, especially those born in Eastern Europe, and were unexpectedly high among children (H: 4.3%; S: 4.6%). Foreign-born cases had significantly higher proportion of any resistance (16.0%) and MDR-TB (3.3%) compared to German-born cases (8.3% and 0.6%). Of 556 MDR-TB cases, 39.2% showed complete HRZES resistance. Logistic regression revealed having prior TB and being foreign-born as consistently strong risk factors for any DR, MDR-TB, and complete HRZES resistance. CONCLUSIONS: DR patterns observed in Germany, particularly for MDR-TB were more complex than expected, highlighting the fact that detailed drug-testing results are crucial before incorporating HRZES drugs in MDR-TB treatment. Furthermore, the relatively high rate of H-resistance in Germany provides strong rationale against the use of only H-based preventive therapy for LTBI.

Correlates and Determinants of Cardiorespiratory Fitness in Adults: a Systematic Review.

BACKGROUND: Enhanced cardiorespiratory fitness (CRF) is now a well-established predictor of numerous adverse health outcomes. Knowledge about the pathways leading to enhanced CRF is essential for developing appropriate interventions. Hence, the aim of this review was to provide a detailed overview of the current state of research regarding individual factors associated with or influencing CRF among the general adult population. METHODS: We searched the PubMed, EMBASE, and Cochrane Library databases and also conducted a search for grey literature (Google Scholar). Eligible indicators of CRF were objectively assessed measures of CRF by submaximal or maximal exercise testing measured using treadmill or cycle ergometer tests. We included quantitative observational studies of the general adult population. Using a semi-quantitative approach, we compiled summary tables aggregating the study results for each potential correlate or determinant of CRF. RESULTS: We identified 3005 studies, 78 of which met the inclusion criteria. Almost all of these studies were conducted in high-income countries. Study quality scores assessing the risk of bias in the individual studies ranged from 40 to 100%. Male sex, age (inverse), education, socioeconomic status, ethnicity, body mass index (inverse), body weight (inverse), waist circumference, body fat (inverse), resting heart rate (inverse), C-reactive protein (inverse), smoking (inverse), alcohol consumption, and multiple measures of leisure-time physical activity were independently and consistently associated with CRF. CONCLUSIONS: In synthesizing the current research on the correlates and determinants of CRF among adults, this systematic review identified gaps in the current understanding of factors influencing CRF. Beyond the scope of this review, environmental and interpersonal determinants should be further investigated. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42017055456.

Comparing individual and area-based income measures: impact on analysis of inequality in smoking, obesity, and diabetes rates in Canadians 2003-2013.

OBJECTIVES: The aims of this study were to examine (1) the concordance between income measured at the individual and area-based level and (2) the impact of using each measure of income on inequality estimates for three health indicators-the prevalence, respectively, of diabetes, smoking, and obesity. METHODS: Data for the health indicators and individual income among adults came from six cycles of the Canadian Community Health Survey (cycles 2003 through 2013). Area-based income was obtained by linking respondents' residential postal codes to neighbourhood income quintiles derived from the 2006 Canadian census. Relative and absolute inequality between the lowest and highest income quintiles for each measure was assessed using rate ratios and rate differences, respectively. RESULTS: Concordance between the two income measures was poor in the overall sample (weighted Kappa estimates ranged from 0.19 to 0.21 for all years), and for the subset of participants reporting diabetes, smoking, or obesity. Despite the poor concordance, both individual and area-based income measures identified generally comparable levels of relative and absolute inequality in the rates of diabetes, smoking, and obesity over the 10-year study period. CONCLUSION: The results of this study show that individual and area-based income measures categorize Canadians differently according to income quintile, yet both measures reveal striking income-related inequalities in rates of diabetes and smoking, and obesity among women. This suggests that either individual or area-level measures can be used to monitor income-related health inequalities in Canada; however, whenever possible, it is informative to consider both measures since they likely represent distinct social constructs.

Socioeconomic Correlates and Determinants of Cardiorespiratory Fitness in the General Adult Population: a Systematic Review and Meta-Analysis.

BACKGROUND: This review aims to (1) consolidate evidence regarding the association between socioeconomic status (SES) and cardiorespiratory fitness (CRF), (2) conduct a meta-analysis of the association between SES and CRF using methodologically comparable data, stratified by sex, and (3) test whether the association varies after adjustment for physical activity (PA). METHODS: A systematic review of studies from MEDLINE, EMBASE, Latin American and Caribbean Health Sciences (LILACS), Scientific Electronic Library Online (ScIELO), and Cochrane Library without time or language restrictions, which investigated associations between SES and CRF. Risk of bias within studies was assessed using a customized quality assessment tool. Results were summarized in table format and methodologically similar studies were synthesized using meta-analysis of Hedges' g effect sizes. Synthesized results were appraised for cross-study bias. Results were tested for the impact of PA adjustment using meta-regression. RESULTS: Compared to individuals with low education, both men and women showed higher CRF among individuals with high education (men 0.12 [0.04-0.20], women 0.19 [0.02-0.36]), while participants with medium education showed no significant difference in CRF (men 0.03 [- 0.04-0.11], women 0.09 [- 0.03-0.21]). Adjustment for PA did not significantly impact the association between education and CRF. CONCLUSIONS: There is fair evidence for an association between high levels of education and increased CRF. This could have implications for monitoring, of health target compliance and of chronic disease risk among higher risk populations, to detect and prevent non-communicable diseases (NCDs) and to diminish social health inequalities. TRIAL REGISTRATION: PROSPERO, CRD42017055456.

Why are some people more fit than others? Correlates and determinants of cardiorespiratory fitness in adults: protocol for a systematic review.

BACKGROUND: Cardiorespiratory fitness (CRF) is a physical condition that is now well established as a predictor of numerous adverse health outcomes, independent of physical activity levels. In order to be able to improve CRF at the population level and to develop effective interventions and public health programmes, it is important to understand why some people are more fit than others. Therefore, the primary aim of the systematic review described in this protocol is to examine individual and interpersonal factors that are correlated with or determine CRF among adults. METHODS: The review will focus on quantitative studies that investigate any personal and interpersonal correlates and/or determinants of objectively measured CRF among the general, non-symptomatic, non-institutionalized adult population (aged 18-65 years) worldwide. The databases MEDLINE, Embase, and Cochrane Library will be searched to identify all relevant published journal articles, and Google Scholar and Scopus will be searched for grey literature. Studies where CRF is not an outcome variable and experimental studies where participants specifically receive a fitness intervention that increases CRF will be excluded. For each study, data extracted will include, among other variables, study characteristics, methodology for selecting participants into the study as well as the participants' demographic characteristics, types of correlates and determinants of CRF investigated and their measurement methods, the objective measure of CRF used and its measurement method and validity, and the main reported results on the association between the correlates or determinants and CRF. In addition, observational studies will be assessed for methodological quality and risk of bias using a customized version of the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies by the National Heart, Lung, and Blood Institute. Experimental studies will be assessed using the 27-item Downs and Black "Checklist for Measuring Study Quality". The final results will be presented as a narrative synthesis of the main findings of all included studies. DISCUSSION: By consolidating and synthesizing the current research on possible individual and interpersonal correlates and determinants of CRF among adults worldwide, we aim to aid future public health actions, as well as identify gaps in our full understanding of what influences CRF. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017055456 .