Anti-Leptospira Seroprevalence and Associated Risk Factors among Forestry Workers in Lower Saxony, North-West Germany.

As leptospirosis is re-emerging, a seroprevalence study was conducted, assessing the prevalence of anti-Leptospira IgG antibodies and infection-associated risk factors among forestry workers (FWs) in Lower Saxony, Germany, to develop targeted public health measures. Sera of 877 FWs, sampled in 2016, were tested for anti-Leptospira seropositivity by commercial IgG-ELISA. Data on demographics and Leptospira-specific exposures, knowledge, sources of information, and preventive measures were collected by standardized, self-administered questionnaire. A subset of 244 sera was retested via in-house IgG-ELISA. Risk factors were assessed from the subset using multivariable logistic regression analysis. The commercial IgG-ELISA revealed a seroprevalence of 4.8% (95% confidence interval CI95 = 3.5-6.4). Of the 601 FWs who completed the questionnaire, 67.9% had been informed about leptospirosis and Leptospira spp., mainly by employers (55.2%) and peers (38.9%). Positive associations with seropositivity were observed for canoeing (adjusted odds ratio (aOR) = 2.35, p = 0.044), touching rodents (aOR = 2.4, p = 0.021), and living close to beech trees (aOR = 2.18, p = 0.075). Frequently cleaning animal stables was negatively associated (aOR = 0.20, p = 0.002). The unexpected positive association with wearing gloves when handling plants and soil (aOR = 2.16, p = 0.011) needs further discussion. Overall, seroprevalence was in the range of other studies in Germany. The identified factors will be used to develop targeted information reaching out to at-risk groups tapping various communication channels.

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.

Characteristics of Animal-assisted Interventions in the state of Lower Saxony, Germany, with a focus on hygiene in health care facilities.

Animal-assisted Interventions (AAIs) are becoming increasingly popular. To date, information on the extent of AAIs in Germany is limited. With a focus on infection control measures in health care facilities (HCFs), two studies were conducted in Lower Saxony to gain knowledge about the structure, characteristics and frequency of AAIs. An online survey among AAI providers identified dogs as the most important animal species in AAI, which mainly operated in educational facilities (53%) and/or on own property (46%). Twenty-nine percent offered their services in HCFs. The majority (55%) of the animal handlers was highly trained in AAI, but their awareness of hygiene and infection control measures to prevent zoonotic disease transmission was limited. Nineteen percent of animal handlers dewormed dogs only when faecal examinations were positive and 13% of dogs received ectoparasiticides only when infestations were present. Raw meat diets were frequent (82%). There was little awareness among animal handlers about the possibility of a zoonotic transmission from the client to the animal. Thus, handling of therapy dogs often reflected that of a "normal" pet ownership and did not always account for the special situation in HCFs. A telephone survey in 148 hospitals showed that 28% of the hospitals had experiences with animal-assisted therapies or animal visits, but 22% of these were lacking regulations on handling these animal contacts. While 28% of all hospitals had regulations for assistance dogs only 5% were aware of a new law that grants people accompanied by an assistance dog broad admission rights to public spaces, including HCFs. With an expected further increase in popularity of AAIs high quality standards which include infection control measures and animal welfare should be adopted by all AAI providers and recipients. This will ensure a safe implementation of this complementary medicine, where both sides - the human and the animal - can benefit.

Pandemic management: Analysis of availability and relevance of surveillance indicators by COVID-Task-Forces in the German federal state of Lower Saxony.

Background: Locally, the introduction of measures during times of a pandemic emergency is embodied in a pandemic containment plan created by the Robert Koch Institute in 2017. In addition to central indicators such as incidence rates and number of deaths, various indicators are used at the local level to assess the pandemic situation. So far, there hasn't been analyses of the availability and perceived relevance of the surveillance indicators used to manage the SARS-CoV-2 pandemic by the local German pandemic task forces. Aim: This study examined whether local decision-makers had access to surveillance-related indicators in a way that they could be used to make informed decisions in response to the pandemic situation. Methods: A cross sectional study was conducted, using an online questionnaire developed by experts of The Public Health Agency of Lower Saxony and The University Medical Center Göttingen (UMG). All local COVID-19 task forces of the German state of Lower-Saxony were enrolled in the study. Findings: The surveillance indicators assessed by survey respondents as most available and relevant are included under the German Infection Protection Act (IfSG). In contrast, the indicators that are not bound by the IfSG have a significantly lower availability and an inconsistent assessment of relevance. Conclusion: Against the background of efficiency, it seems central to be able to reliably provide the highly weighted surveillance indicators. Nevertheless, the relevance assessment gap between the indicators embedded in the IfSG and the ones that are not may be explained by cognitive processes such as anchoring bias. The collection and use of indicators to assess the pandemic situation and to evaluate measures should be the subject of continuous multidisciplinary discussions.

[Integrating Public Health Expertise in Research: a Series of Workshops about Vector-Borne and Other Zoonotic Diseases]. / ÖGD-Expertise in die Forschung bringen: eine Workshop-Reihe zu vektorübertragenen und weiteren zoonotischen Erkrankungen.

Research groups must understand the needs and requirements of the public health service to be able to develop tools and strategies for supporting it in risk assessment and risk communication. The zoonotic research consortia RoBoPub, Q-GAPS, TBENAGER and ZooBoCo used the format of workshops to include the expertise of the public health service system in their work. We present the results of three workshops that were held with representatives of the German public health service as part of the annual congress of the Federal Association of Physicians of German Public Health Departments in 2018, 2019 and 2022. Each workshop, held in a world-café format, lasted 90 minutes and had its own thematic focus. In the first workshop, information on the goals, problems, solutions and expectations of the public health service from the research consortia concerning exposure to rodent-borne infections during their occupational and leisure-time activities as well as the use of risk maps was collected. In the second and third workshops, participants developed risk communication strategies based on scenarios of outbreaks and identifications of new risk areas. Each workshop had more than 20 participants, of which at least half worked for local public health authorities. Foremost, participants expected practical, target group-specific material for risk communication from the research groups. According to the experience of most participants, direct contact with the affected groups was essential for risk communication. To raise awareness of the situation and establish contact with the relevant target groups, social media can complement traditional media, especially for hard-to-reach groups. However, their use should be considered and planned carefully. The workshop format was appropriate for integrating the public health expertise in the research activities. The expectations of the public health service on material for risk communication could be translated into a guideline, a risk management plan and pathogen descriptions by the research groups. When integrating the expertise of the public health authorities in their work, research groups should consider how to reach a suitable panel of representatives and how to keep the workload for those at an acceptably low level.

[Viral zoonoses in Germany: a One Health perspective]. / Virale Zoonosen in Deutschland aus der One Health-Perspektive.

The COVID-19 pandemic and the increasing occurrence of monkeypox (mpox) diseases outside Africa have illustrated the vulnerability of populations to zoonotic pathogens. In addition, other viral zoonotic pathogens have gained importance in recent years.This review article addresses six notifiable viral zoonotic pathogens as examples to highlight the need for the One Health approach in order to understand the epidemiology of the diseases and to derive recommendations for action by the public health service. The importance of environmental factors, reservoirs, and vectors is emphasized, the diseases in livestock and wildlife are analyzed, and the occurrence and frequency of diseases in the population are described. The pathogens selected here differ in their reservoirs and the role of vectors for transmission, the impact of infections on farm animals, and the disease patterns observed in humans. In addition to zoonotic pathogens that have been known in Germany for a long time or were introduced recently, pathogens whose zoonotic potential has only lately been shown are also considered.For the pathogens discussed here, there are still large knowledge gaps regarding the transmission routes. Future One Health-based studies must contribute to the further elucidation of their transmission routes and the development of prevention measures. The holistic approach does not necessarily include a focus on viral pathogens/diseases, but also includes the question of the interaction of viral, bacterial, and other pathogens, including antibiotic resistance and host microbiomes.

[Bacterial zoonoses of public health importance in Germany-incidence, distribution, and modes of transmission]. / Bakterielle Zoonosen mit Bedeutung für den öffentlichen Gesundheitsschutz in Deutschland ­ Vorkommen, Verbreitung und Übertragungswege.

Bacterial zoonotic pathogens are often the cause of diseases, sometimes with severe outcomes. They are mutually transferable between animals (both wild and domestic) and humans. The transmission paths are very variable and include oral intake via food, respiratory infection via droplets and aerosols, or infections via vectors such as tick bites or rodent contact. Furthermore, the emergence and spread of antibiotic-resistant bacterial pathogens is of paramount public health concern.The likelihood of further spread is influenced by various factors. These include the increase in international trade, the endangerment of animal habitats, and the increasingly closer contact between humans and wild animals. Additionally, changes in livestock and climate change may also contribute. Therefore, research into zoonoses serves to protect human and animal health and is of particular social, political, and economic importance.The aim of this review article is to present the range of infectious diseases caused by bacterial zoonotic pathogens in order to provide a better understanding of the important work in public health services, animal health services, and food safety control. The different transmission routes, epidemic potentials, and epidemiological measures of the exemplary selected diseases show the challenges for the public health system to monitor and control the spread of these bacterial pathogens in order to protect the population from disease.

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.

Multicenter Preparedness Exercise Enables Rapid Development of Cluster-Specific PCR-Based Screening Assays from Bacterial Genomic Data.

PCR-based screening assays targeting strain-specific genetic markers allow the timely detection and specific differentiation of bacterial strains. Especially in situations where an infection cluster occurs, fast assay development is crucial for supporting targeted control measures. However, the turnaround times (TATs) for assay setup may be high due to insufficient knowledge about screening assay methods, workflows, and software tools. Here, two blind-coded and quality-controlled ring trials were performed in which five German laboratories established PCR-based screening assays from genomic data that specifically target selected bacterial clusters within two bacterial monospecies sample panels. While the first ring trial was conducted without a time limit to train the participants and assess assay feasibility, in the second ring trial, a challenging time limit of 2 weeks was set to force fast assay development as soon as genomic data were available. During both ring trials, we detected high interlaboratory variability regarding the screening assay methods and targets, the TATs for assay setup, and the number of screening assays. The participants designed between one and four assays per cluster that targeted cluster-specific unique genetic sequences, genes, or single nucleotide variants using conventional PCRs, high-resolution melting assays, or TaqMan PCRs. Assays were established within the 2-week time limit, with TATs ranging from 4 to 13 days. TaqMan probe delivery times strongly influenced TATs. In summary, we demonstrate that a specific exercise improved the preparedness to develop functional cluster-specific PCR-based screening assays from bacterial genomic data. Furthermore, the parallel development of several assays enhances assay availability.

Pet Rats as the Likely Reservoir for Human Seoul Orthohantavirus Infection.

Seoul orthohantavirus (SEOV) is a rat-associated zoonotic pathogen with an almost worldwide distribution. In 2019, the first autochthonous human case of SEOV-induced hemorrhagic fever with renal syndrome was reported in Germany, and a pet rat was identified as the source of the zoonotic infection. To further investigate the SEOV reservoir, additional rats from the patient and another owner, all of which were purchased from the same vendor, were tested. SEOV RNA and anti-SEOV antibodies were found in both of the patient's rats and in two of the three rats belonging to the other owner. The complete coding sequences of the small (S), medium (M), and large (L) segments obtained from one rat per owner exhibited a high sequence similarity to SEOV strains of breeder rat or human origin from the Netherlands, France, the USA, and Great Britain. Serological screening of 490 rats from breeding facilities and 563 wild rats from Germany (2007-2020) as well as 594 wild rats from the Netherlands (2013-2021) revealed 1 and 6 seropositive individuals, respectively. However, SEOV RNA was not detected in any of these animals. Increased surveillance of pet, breeder, and wild rats is needed to identify the origin of the SEOV strain in Europe and to develop measures to prevent transmission to the human population.

Investigation and response to a large outbreak of leptospirosis in field workers in Lower Saxony, Germany.

Between June and August 2014, 45 cases of leptospirosis were notified among workers on two strawberry farms in North-West Germany. We describe the characteristics of the outbreak and the actions taken to prevent further cases. The activities of the local, federal and national public health and veterinary authorities included collection of case data, laboratory testing of human specimens and of small mammals trapped on the fields, investigation of weather data, as well as information provided to farmers, field workers, physicians and to the authorities in Poland and Romania. Of the 45 identified cases (median age 22, 60% male), 47% were hospitalized. Characteristic symptoms were fever ≥38.5°C, generalized muscle pain and an increase in renal or liver enzymes. Thirteen cases were laboratory confirmed by serological and/or molecular methods. ELISA tests for Leptospira IgG and IgM-antibodies were positive in those samples taken >5 days after hospitalization. The probable causative agent was identified as Leptospira kirschneri serovar Grippotyphosa. Leptospira-specific DNA was found in kidneys of 67% of 64 trapped small mammals and was further identified as Leptospira kirschneri multi locus sequence type 110. During the estimated time period of human infections, the affected region faced warm weather with heavy rainfalls. The results of this investigation are in accordance with the theory of a chain of infection from mice to field workers during warm and humid weather. In 2015, a campaign was initiated to inform physicians, farmers and workers to enhance prevention measures, such as the use of personal protective equipment and early consultation of physicians in case of illness. Since then, no further outbreak occurred.

Risk factors for Leptospira seropositivity in rural Northern Germany, 2019.

We investigated seroprevalence and factors associated with Leptospira spp. infections in humans in rural Northern Germany. Sera of 450 participants were tested for leptospira-reactive IgG antibodies by two enzyme-linked immunosorbent assays (ELISA). A narrow (specific) and a broad (sensitive) case definition were applied and results compared in the analysis. Personal data were collected via questionnaire and associations with the serostatus were investigated by multivariable logistic regression. The seroprevalence estimates were 1.6% (95%-confidence interval (CI) = 0.63-3.2) under the narrow and 4.2% (95%-CI = 2.6-6.5%) under the broad case definition. Few (14%) participants knew about the pathogen. No seropositive participant recalled a prior leptospirosis diagnosis. Spending more than two hours a week in the forest was significantly associated with anti-leptospira IgG in both models (broad case definition: adjusted odds ratio (aOR) = 2.8, 95%-CI = 1.2-9.1; narrow case definition: aOR = 11.1, 95%-CI = 1.3-97.1). Regular cleaning of storage rooms was negatively associated in the broad (aOR = 0.17, 95%-CI = 0.03-0.98) and touching a dead rodent in the past 10 years in the narrow case definition model (aOR = 0.23, 95%-CI = 0.05-1.04). Our findings support risk factors identified in previous investigations. To counter the low awareness for the pathogen, we recommend that health authorities communicate risks and preventive measures to the public by using target-group specific channels.

Cluster of human Puumala orthohantavirus infections due to indoor exposure?-An interdisciplinary outbreak investigation.

Puumala orthohantavirus (PUUV) is the most important hantavirus species in Europe, causing the majority of human hantavirus disease cases. In central and western Europe, the occurrence of human infections is mainly driven by bank vole population dynamics influenced by beech mast. In Germany, hantavirus epidemic years are observed in 2- to 5-year intervals. Many of the human infections are recorded in summer and early autumn, coinciding with peaks in bank vole populations. Here, we describe a molecular epidemiological investigation in a small company with eight employees of whom five contracted hantavirus infections in late 2017. Standardized interviews with employees were conducted to assess the circumstances under which the disease cluster occurred, how the employees were exposed and which counteractive measures were taken. Initially, two employees were admitted to hospital and serologically diagnosed with hantavirus infection. Subsequently, further investigations were conducted. By means of a self-administered questionnaire, three additional symptomatic cases could be identified. The hospital patients' sera were investigated and revealed in one patient a partial PUUV L segment sequence, which was identical to PUUV sequences from several bank voles collected in close proximity to company buildings. This investigation highlights the importance of a One Health approach that combines efforts from human and veterinary medicine, ecology and public health to reveal the origin of hantavirus disease clusters.

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.

[Leptospirosis in Germany: current knowledge on pathogen species, reservoir hosts, and disease in humans and animals]. / Leptospirose in Deutschland: Aktuelle Erkenntnisse zu Erregerspezies, Reservoirwirten und Erkrankungen bei Mensch und Tier.

Leptospirosis is a zoonotic disease with a wide spectrum of clinical symptoms in humans and animals, ranging from subclinical infections to severe signs of multiorgan dysfunction. In Germany, laboratory confirmation of acute human infection is notifiable based on the Protection Against Infection Act. Disease or occurrence of the pathogen in pigs and sheep must be reported according to the regulation on reportable animal diseases. Transmission occurs via direct and indirect contact with the urine of infected animals, with rodents acting as the main reservoir. With an average annual incidence of 0.1 notified cases per 100,000 inhabitants, leptospirosis is a rare disease in Germany.This review article presents the current knowledge on leptospirosis in Germany in the framework of the project "Improving public health through a better understanding of the epidemiology of rodent-transmitted diseases" (RoBoPub) funded by the Ministry of Education and Research. In a One-Health approach, information about clinical manifestation, available prevalence data in humans and animals, knowledge of pathogen distribution, host association, mode of transmission, and survival in the environment is summarized. Preliminary findings on the influence of fluctuations in rodent populations on the occurrence of leptospirosis are also discussed. The aim of the article is to increase the awareness of this currently neglected disease in Germany.In future, higher temperatures and more frequent heavy rainfalls, which could occur due to climate change, should be taken into account.

[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.

Sociodemographic determinants of spatial disparities in early childhood caries: An ecological analysis in Braunschweig, Germany.

OBJECTIVES: To identify spatial disparities in dental caries experience (measured by dmft (decayed missing filled teeth) index) of children in the city of Braunschweig and to evaluate whether these disparities can be explained by sociodemographic characteristics. METHODS: We examined the dental health of children aged 3-6 years visiting a daycare centre (DCC) in the metropolitan area of Braunschweig between 2009 and 2014 by combining data on dental health from the annual visits of the local health service with aggregated data on sociodemographic factors for Braunschweig's city districts. We assessed longitudinal patterns of change in average dmft index at district level from 2009 to 2014 using a finite mixture model. We analysed spatial autocorrelation of the district's average dmft indices by Moran's I to identify spatial clusters. With a spatial lag model, we evaluated whether sociodemographic risk factors (data from 2012) were associated with high dmft scores (data from 2014) and whether spatial disparities remained after adjusting for these sociodemographic characteristics. RESULTS: The average dmft index decreased slightly (ß=-0.048; P<.03; CI 95% [-0.079; -0.017]) from 2009 to 2014. The finite mixture model resulted in four different groups of trajectories over time. While three groups showed a decrease in dmft score, one group showed an increase from 2009 to 2014. Moran's I test statistic showed strong evidence for spatial clustering (Moran's I 0.30, P=.002). A cluster of districts with high dmft values was identified in the centre of the city. The spatial lag model showed that both the proportion of unemployed persons (aged 16-65) and the proportion of persons with migration background were associated with the dmft values at district level. After adjusting for these, no further spatial heterogeneity was observed. CONCLUSION: We identified regional clusters for poor dental health in a German city and showed that these clusters can be explained by sociodemographic characteristics. The findings support the need of targeted interventions and prevention measures in regions with less favourable sociodemographic characteristics.