Analysis of the surveillance situation for viral encephalitis and meningitis in Europe.

Infective processes in the brain, spinal cord and meninges are considered to be the main causes of encephalitis, myelitis and meningitis. However, most cases remain unexplained. The incidence of different viral aetiologies (zoonotic and non-zoonotic) is especially poorly estimated, due to the lack of a standard case definition and of agreed diagnostic algorithms, including harmonised diagnostic methods and sample collection. It is important to clarify the incidence of viral encephalitis/meningitis and to optimise the diagnosis of infectious neurological illness, particularly to ensure early recognition of outbreaks or emerging infectious such a West Nile encephalitis. The European Network for Diagnostics of 'Imported' Viral Diseases (ENIVD) has analysed the present surveillance situation for viral encephalitis/meningitis in Europe. Here we give an overview of the existing epidemiological sources of information in European Union (EU) Member States, mapping the laboratory capacity and identifying key requirements for a possible future surveillance study at European level. The data presented will help design a harmonised/standardised Europe-wide surveillance study investigating patients with encephalitis and/or meningitis in order to obtain more information on the role of infections in these rarely analysed syndromes, both from a clinical and an epidemiological perspective.

Legionnaires' disease outbreak associated with a cruise liner, August 2003: epidemiological and microbiological findings.

Eight cases of Legionnaires' disease were identified among the 215 German passengers after a cruise to the Nordic Sea in August 2003. An unmatched case-control study was conducted to identify risk factors and the source of infection. In total, eight passengers fulfilled the case definition, one of these died. Forty-two passengers served as controls. The attack rate was 4%. The mean age was 60 years for cases and 62 years for controls. Prolonged exposure to the spa pool seemed to be a risk factor of infection (OR 4.85, P=0.09). Legionella pneumophila serogroup 1, monoclonal antibody (mAb) subgroup 'Knoxville' was isolated from clinical and environmental samples. DNA sequence-based typing revealed that these isolates were indistinguishable from each other. The investigation showed the importance of an interdisciplinary approach of microbiology and epidemiology as not all sites on the ship that tested positive for L. pneumophila actually posed a relevant risk for the passengers.

Cross-protection against homologous drift variants of influenza A and B after vaccination with split vaccine.

The aim of this serological study was to demonstrate the extent to which antibodies react against subsequent drift variants, after vaccination with split vaccine (Fluarix). Antibody titers have been determined by hemagglutination inhibition test (HI) against different influenza A and B drift variants in sera from three past multicenter trials. Individuals of two different age groups, i.e. 18-60 years and above 60 years, were enrolled. Vaccine components influenza A/H1N1 and influenza B of Fluarix show a high degree of cross immunogenicity against subsequent homologous drift variants. The genetically more variable component influenza A/H3N2 shows somewhat lower protection rates. High levels of cross immunogenicity were found between the variants of influenza A/Panama/2007/99 (H3N2) and influenza A/Wyoming/3/2003 (H3N2). The results demonstrate that in situations where drift variants emerge too late to be included in the influenza vaccine formulation, the cross-protection conferred must be evaluated on a case-by-case basis.

[Surveillance of acute respiratory illnesses (ARI) in Lower Saxony: first experience from the years 2005-2006]. / Surveillance akuter respiratorischer Erkrankungen (ARE) in Niedersachsen: Erste Erfahrungen aus den Jahren 2005-2006.

In the context of influenza pandemic preparedness planning, a surveillance system for influenza and other acute respiratory illnesses was implemented in Lower Saxony at the beginning of the influenza season 2004/2005 and coordinated by the Governmental Institute of Public Health of Lower Saxony. This surveillance system represents an addition to already existing national monitoring systems. The goal of this surveillance system is to have available prompt information on the beginning, course and end of the influenza season and to recognise the spectrum of pathogens and identify outbreaks of other viral acute respiratory illnesses (ARI). For this purpose an all-season surveillance was established consisting of two supplementary modules. The first module is a symptom-oriented surveillance of acute respiratory illnesses in children of pre-school day care facilities. In the second module a virological surveillance in co-operation with selected medical practices was established. While the temporal course and burden of ARI in all Lower Saxony can be assessed by the surveillance of children in the day-care facilities in a sensitive, but less specific way, the virological surveillance provides highly specific information on the prevailing pathogens in ARI patients at a certain time. This information, in return, gives an indication about the responsible pathogens causing ARI in children of the day-care facilities. The first experience with these two complementary surveillance modules shows that in Lower Saxony a well accepted, prompt and meaningful monitoring system is available for the recognition and description of the occurrence of ARI and concomitantly of influenza. An extension of this surveillance to other pathogens or disease scenarios is possible.

[Public health service as cooperative partner in prevention]. / Der öffentliche Gesundheitsdienst als Kooperationspartner in der Prävention.

As resources become scarce there is increasing demand on the public health services to create a system of community-based and jointly used health protection services. Cohort surveys that are currently more and more reduced contribute to both primary and secondary prevention. They enable third parties to implement further prevention projects. In addition, due to continuous quality assessment and standardization process, they yield valid data for developing target-group-specific prevention strategies as well as for evaluating preventive measures. In this respect public health services already fulfil the demand for prevention in the social environment as outlined in the forthcoming Prevention Act. Preventive measures in the field of dental health, atopic diseases and vaccination are presented as examples. The integration of data from continuous cohort surveys into a health reporting system as a basis for developing and evaluating health targets and prevention projects at the state level is demonstrated.

[Poliomyelitis--why we must continue to vaccinate!]. / Poliomyelitis weltweit vor der Eradikation. Warum wir jetzt unbedingt weiterimpfen müssen.

The eradication of polio--that is the worldwide elimination of the wild poliovirus--is now within reach. The current success of this international project is due largely to the rigorous immunization of the general population. Both live oral polio vaccine (OPV) and inactivated vaccine (IPV) administered by injection are applied, the pros and cons of each having to be weighed up. Since 1998, only the dead IPV vaccine has been recommended in Germany. It is essential that the acceptance of the need for immunization should not decline, and that the inoculation rate in countries in which polio has apparently been eliminated, should not fall below the critical threshold of about 85-80%. If in the future this figure is not reached, the population would be put at risk by the re-introduction of the polio virus into the country. Even when global elimination has been achieved, vaccination must be continued for several years. The recommended immunization schedule covers three vaccinations for basic immunization plus a booster vaccination in adolescence.

[Surveillance system for assessing central nervous infections in Lower Saxony 1998-2000]. / Surveillance-System zur Erfassung zentralnervöser Infektionen in Niedersachsen 1998-2000.

OBJECTIVE AND METHOD: In cooperation with the district public health authorities in Lower Saxony a surveillance system for infections of the central nervous system was established from 1998 to 2000. Reporting was based on special questionnaires. It was the objective of this system to obtain information on the pathogens responsible for these infections and the corresponding age distribution. RESULTS: An increased risk was found for children under the age of 15. About two-thirds of all reported central nervous infections were observed in this age group. The most frequent bacteria identified had been Meningococci, Pneumococci and Borrellia burgdorferi. They accounted for about 56 % of the reported bacterial infections. With respect to viral meningitis/encephalitis, enteroviruses were isolated in about 66 % of these cases. Twenty-five of all 628 reported cases had a lethal outcome which was more often associated with bacterial than viral infections. CONCLUSIONS: Infections of the central nervous system still play an important role in clinical and public health medicine. For the future an intensive and ongoing surveillance of these infectious diseases is required and should exceed the regulations of the official notification system. To this end, a prospective register for meningitis and encephalitis cases will be set up in Lower Saxony in cooperation with hospitals and laboratories.

[Economic evaluation of various hepatitis B vaccination strategies in children and adolescents]. / Okonomische Evaluation verschiedener Hepatitis-B-Impfstrategien bei Kindern und Jugendlichen.

AIM: In this cost-effectiveness study 4 different vaccination strategies against hepatitis B in children and adolescents are evaluated and compared with the situation without immunization. EXAMINATION: Projections are made for the population of the today's adolescents underage 15 and the newborns of the next 30 years. The number of avoided hepatitis B virus (HBV) infections and the cases of disease as well as the costs associated with treatment and vaccination are determined. The course of incidence of the hepatitis B virus is observed for different age groups. RESULTS: Compared to the situation without any vaccination against hepatitis B, a decrease of the remaining infections of at least 18,900 up to 46,600 could be expected during the next 30 years. The treatment costs for the remaining cases of disease could be reduced by 0.4 up to 1.6 billions DM. The remaining expenditures for treatment and vaccination would be limited to 2.3 up to 3.4 billions DM. The net costs of a vaccination are determined as about 14,200 up to 63,000 DM per avoided case of infection. Considering the commonly accepted number of unreported cases of hepatitis B as to be the 5- to 10 fold of the known incidence, all of the 4 compared vaccination strategies will be cost-effective and associated with net savings of about 5,900 up to 36,400 DM per avoided case of hepatitis B virus infection during 30 years. The epidemiological situation will be positive influenced by such a mass vaccination. The minimization of incidence is shown for the different age groups. CONCLUSION: Considering these economical arguments, first the vaccination of all adolescents between age 11 to 15 and second the vaccination of all children/adolescents between age 0 to 15 are the preferable strategies. The immunization of all children/adolescents between age 0 to 15 is the most effective strategy from an epidemiological point of view.

[Education and continued education in public health. Wishes and reality at the present time; demands for the future]. / Aus- und Fortbildung im öffentlichen Gesundheitsdienst. Wunsch und Wirklichkeit in der Gegenwart; Ansprüche an die Zukunft.

Sociomedicine in research and practice, i.e. in universities and in public health services, has experienced an upswing many had not expected. The health requirements of society and not only those of the individual have gained a new topicality as social factors were rediscovered in connection with health. Public health services can be advisors to politicians and defence attorneys for the population by assuming a new role and a new measure of self-understanding in the realisation of old but always fresh topics such as environmental medicine (formerly known as environmental hygiene). To translate the multitude of sociomedical tasks effectively into reality, the practically active sociomedical officer in public health services stands in need of the backing and help by sociomedical researchers in the relevant university departments. It will be imperative to achieve in future a greatly improved and closer cooperation between research and practice in sociomedicine.

[Vaccination against Haemophilus influenzae B and rubella]. / Impfungen gegen Haemophilus influenzae B und Röteln.

Haemophilus influenzae B was the most frequent pathogen of bacterial meningitis in childhood during the mid-eighties to the end of the eighties of the present century, taking the place of meningococci since approximately 1984 at about twice the rate of that pathogen, as shown by the records kept during 1980-1990 in Bavarian Departments of Paediatrics. In fact, in 1990 the incidence of HIB meningitides was about 2.5 times that of meningococcus meningitides (85 vs. 34, respectively). For practically 2 years now vaccination against HIB is being publicly recommended and should be made use of as intensively as possible to prevent all HIB infections. For several years the principle of on-target rubella vaccination has been applied to schoolgirls in Lower Saxony, Bremen and Hamburg to prevent rubella embryopathy, a procedure that has proved much more successful than blank vaccination. None of the other Federal German Laender have been following this procedure to date; in consequence there of, although the strategy of on-target vaccination will be continued in Lower Saxony, greater uniformity and greater efficiency are being aimed at throughout Germany by public recommendation of rubella vaccination at an infant age.

[Determinants of lead concentration in the umbilical cord blood of 9189 newborns of a birth cohort in the government district of Braunschweig]. / Determinanten der Bleikonzentration im Nabelschnurblut von 9189 Neugeborenen eines Geburtsjahrgangs im Regierungsbezirk Braunschweig.

From September 1985 until August 1986 the possibility of lead concentration determination in umbilical cord blood was offered to all neonates in the district of Braunschweig by the Ministry of Social Affairs of Lower Saxony. A geometric mean concentration of 3.76 +/- 1.69 micrograms Pb/dl was found in 9189 neonates, being 64% of the total birth cohort. The median concentration was 3.59 micrograms/dl. 4.7% of the children showed concentrations of above 10 micrograms/dl. Lead concentrations of twins showed a strong linear correlation (r = + 0.94). They were higher than those of singleton births (p = 0.02). Lead concentrations in neonates were significantly associated with the age of the mother and with the birthweight of the newborn. Seasonal differentials were significant with higher values in summer (4.39 +/- 1.8 micrograms Pb/dl) compared to winter (3.25 +/- 1.5 micrograms/dl). Duration of daily participation in road traffic was independent of blood lead concentrations. Potential occupational lead exposure of a member of the household was also no significant risk factor for higher lead concentration in the newborn. Family homes constructed before 1955 and those with lead water pipes were associated with significant increases of lead concentrations in neonates. Neighborhood was also significantly associated, with higher values in those living by main roads. In the southern part of the district lead concentrations were about 10% higher than in the northern part. Concentrations in neonates coming from cities were the same as in those coming from rural areas. Newborns from old lead mining and processing areas in the Harz mountains, in particular those coming from Oker-Harlingerode, had low lead concentrations in umbilical cord blood.

[Hepatitis diseases in health occupations (exemplified by Lower Saxony federal land)]. / Hepatitiserkrankungen bei Gesundheitsberufen (Beispiel Bundesland Niedersachsen).

We analysed the incidence of hepatitis among members of the medical profession (doctors, dental surgeons, nurses and medical assistants) by extracting the relevant figures from the total number of hepatitis cases that had been reported to Lower Saxony Public Health authorities between 1976 and 1986. It was found that the incidence and hence the risk of contracting hepatitis A was two to three times higher in particular for the nursing profession than for the total population and also than for doctors and dental surgeons. Although the incidence of hepatitis B has gone down in recent years, the risk of getting infected is definitely higher for doctors, dentists and nursing staff than it is for the total population. This shows that all necessary precautionary and hygiene measures have not yet been fully observed for the members of professions engaged in health care. All persons active in health have an increased risk of being infected with hepatitis non-A-non-B, compared with the overall population. This enhanced risk of hepatitis A infection for the nursing profession and of hepatitis non-A-non-B infection for all medical staff including doctors and dentists prompts us to demand that these two types of disease should also be included in the list of professional diseases.

[Basic health care in developing countries--realization of a desirable dream of the government--demands and tasks of German physicians]. / Basisnahe Gesundheitsversorgung in Entwicklungsländern--Realisierung eines Wunschtraumes der Regierungen--Anforderung und Aufgabe für deutsche Arzte.

PIP: In most newly independent African countries, medical care imitates the Western model, with large urban hospitals containing much of the health care personnel and equipment. A decline in the availability of funds for training and facilities, and the appearance of new diseases provoked by industrialization led to the decline of both the quality and the quantity of medical care, especially in rural areas. In the 1970s, a number of African nations developed a network of ambulatory health facilities and village health workers, thus instituting a Primary Health Care System (PHC-System). Due to logistical and supervisory problems, however, these networks often disintegrated after foreign professionals and administrators departed. They are, nevertheless, prerequisites for the gradual improvement of the health care of rural populations in developing countries. Two basic requirements for their establishment and development are a relatively large personnel and financial investment, and the continuous counselling and supervision of trained nonprofessionals. The tasks which these health workers learn and eventually perform over a 1-2 year period include preventive medicine, counselling patients, providing medicines, reporting to responsible clinics, family planning, child care, and the treatment of a variety of diseases. Preventive measures in the framework of PHC Systems encompass 2 principle areas of hygiene, i.e., provision of clean drinking water and proper disposal of human and other wastes; and innoculations. Providing family planning information is a principle duty of the village health workers. To satisfy minimal rural health care and prevention requirements, regional medical centers serving an area of radius 100 to 150 km are needed to train the village health workers, provide basic medicines, and supply medicine and professional medical supervision to the ambulatory centers.^ieng