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      Tuberculosis surveillance and control in Germany — An application of the Berlin Declaration Monitoring and Evaluation Framework

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          Abstract

          Background

          In 2007, the ‘Berlin Declaration on Tuberculosis’ (BD) was signed by the Ministers of the WHO European Region Member States (MS) to address the re-emerging threat of tuberculosis (TB) by fully implementing the Stop TB strategy. WHO Euro developed a Monitoring and Evaluation (M&E) Framework using programmatic and epidemiological indicators to follow-up the BD from 2013 onwards. Ahead of this, we explored the Framework performance for Germany, a low TB incidence country.

          Methods

          We selected from a surveillance perspective on five country-specific indicators asked for all MS. Information sources included guidelines, notification data and laboratory quality assurance results.

          Results

          As to national TB guidelines (indicator 1.1.1), up-to-date guidance documents are available. Regarding external quality assurance (3.2) proficiency testing confirms high quality of culture and drug-susceptibility testing. M/XDR-TB prevention and control is reflected by a 1.7% MDR-TB rate in 2010 with decreasing tendency (4.1.2). As to treatment success (5), the WHO target of 85% is reached for all age groups except the elderly ≥60 years. Germany disposes of an electronic case-based surveillance providing evidence for TB policy and practices (5.2.2).

          Conclusions

          The selected M&E Framework indicators proved well applicable to a low-incidence country. The results show no specific gaps in TB surveillance and control in Germany.

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          Most cited references 8

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          Is Open Access

          SurvNet Electronic Surveillance System for Infectious Disease Outbreaks, Germany

          Surveillance of infectious disease outbreaks is important because outbreaks often require immediate intervention by the public health service. In addition, outbreaks may indicate deficiencies in infection control management and provide unique opportunities to investigate clinical and epidemiologic characteristics of the infectious agents, particularly in emerging infectious diseases. Timely and comprehensive outbreak reports need to be available not only at the affected administrative level but also at state, national, and international levels to detect and control multistate outbreaks ( 1 – 4 ). Electronic documentation and transmission of data are needed for rapid information exchange between institutions in charge of conducting, coordinating, or reporting control measures and should minimize additional work load for the public health service ( 5 ). International regulations have resulted in increased requirements for outbreak reporting from the local to the international level ( 6 , 7 ). One of the major changes in the new International Health Regulations enacted in May 2005 is that infectious disease outbreaks of international concern must be reported to the World Health Organization, irrespective of the pathogens involved ( 8 ). Moreover, member states of the European Union are already obligated to report foodborne outbreaks to the relevant European Union institution according to the regulation on monitoring of zoonoses and zoonotic agents ( 9 ). Outbreak surveillance for emerging infectious diseases is a particular challenge because small independent outbreaks may occur before they are recognized as part of a larger epidemiologic phenomenon. The complexity, the prolonged persistence of outbreaks, and the differing degree to which outbreaks are investigated locally make it much more difficult to ensure standardized and timely surveillance of outbreaks compared with surveillance of sporadic cases ( 10 ). To overcome these problems, the RKI (the federal institution responsible for infectious disease surveillance in Germany) developed the software and implemented an electronic outbreak reporting system (SurvNet) as part of its existing electronic surveillance system for notifiable diseases. SurvNet was fully implemented in January 2001 at all administrative levels of the German Public Health system and, in January 2006, at all levels of the German armed forces. The objective of the system is timely and easily retrievable epidemiologic information exchange on outbreaks at the local, state, and national levels. We describe the system, present epidemiologic aspects of reported outbreaks, and discuss the strengths and weaknesses after 5 years of practical use in Germany. Material and Methods Electronic Transmission of Data All 431 local health departments in Germany verify locally identified notifiable diseases with reference to national case definitions and send case reports electronically through the 16 state health departments to the national surveillance unit at RKI. The SurvNet software organizes the electronic transmission of case-based datasets from peripheral databases in each local health department to databases of the respective state health department and finally to the RKI ( 11 , 12 ). The system transmits data to the RKI on all cases in Germany but without identifiable information on the persons involved. In contrast, a local health department has full data on all cases from their jurisdiction ( 11 ). The data collected in this system includes demographic characteristics, time, place, diagnostics, case definition criteria, exposure to risk factors, and associations with outbreaks as well as administrative data on where, when, and by whom the dataset is being installed and modified. Outbreak Reporting Single case records can be linked together in the SurvNet database by creating an outbreak report as a new database unit. Several outbreak reports at the local level can be further combined, which results in meta-outbreak reports (Figure). This so called “inverted tree” structure allows documentation of multicounty and multistate outbreaks ( 13 ). Outbreak reports can also be linked with outbreaks that initially were thought to be unlinked but are later identified as being part of the same epidemiologic event. Staff at local or state health departments, as well as at RKI, can electronically link outbreaks on the basis of epidemiologic evidence such as person, place, time, and pathogen; they can also manually enter descriptive categorizations based on the information provided by the outbreak reports that form part of this meta-outbreak (Appendix Figure). Figure Inverted tree structure for organizing electronic outbreak reporting at different administrative levels. Information Structure The qualitative characteristics of the outbreak are covered by 7 sections: geographic setting, food consumption, bloodborne diseases, animal contact, waterborne diseases, person-to-person contact, and molecular fingerprinting. Each section includes a list of standardized items, of which >1 can be selected. Food consumption, for example, contains a selection of standardized food items defined by the first hierarchical order of the Eurocode 2 Food Coding System ( 14 ), a system developed to serve as a standard instrument for nutritional surveys in Europe. Each selected exposure in the different sections is additionally categorized by using standardized evidence categories (Table 1). These range from “exposure confirmed by significant association in case-control or cohort study” to “majority of the cases of this outbreak had this particular exposure.” For example, the category “breach of applicable standard recommendations supports epidemiologic link” is applicable if an outbreak investigation associated with meat consumption shows that consumed meat was not properly cooked. In addition to these standardized variables, results from molecular analysis of pathogens and complementary narrative information, such as anecdotal evidence, can also be included and categorized as “other information.” Table 1 Levels of evidence supporting associations with named exposures, reported infectious disease outbreaks, 2004 and 2005, Germany Level of evidence No. exposures (%) Geographic setting Person-to-person Food Blood Water Animal All Pathogen (in linked person or environmental sample) indicates epidemiologic link 98
(1.4) 3,544
(64.7) 65
(3.8) 4
(1.3) 3
(3.5) 8
(13.6) 3,722
(25.2) Significant association by epidemiologic study (e.g., case control or cohort study) 763
(10.7) 369
(6.7) 139
(8.2) 148
(47.3) 5
(5.9) 2
(3.4) 1,426
(9.7) Most cases had same exposure 6,063
(85.2) 1,361
(24.8) 1,342
(79.4) 60
(19.2) 44
(51.8) 32
(54.2) 8,902
(60.4) Breach of applicable standard recommendations supports epidemiologic link N/A N/A 57
(3.4) 28
(8.9) 3
(3.5) 2
(3.4) 90
(0.6) Other reasons 191
(2.7) 207
(3.8) 88
(5.2) 73
(23.3) 30
(35.3) 15
(25.4) 604
(4.1) All entries 7,115
(100) 5,481
(100) 1,691
(100) 313
(100) 85
(100) 59
(100) 14,744
(100) All outbreaks 7,074 5,400 1,637 311 85 59 14,566 Outbreaks are generally linked to >1 pathogens identified as the causative agent(s) of the outbreak. For notifiable pathogens, the system provides a specific set of variables to allow validation against the respective case definition. Regarding pathogens for which sporadic cases are not notifiable, the agent can be selected from a list of 133 known human pathogens. If a pathogen cannot be detected, the cases can still be transmitted as part of an outbreak. The system automatically generates an outbreak profile consisting of general tables and graphs on the descriptive epidemiology of the outbreak, including epidemic curves, categorizations by age and sex, and geographic distribution of cases. Statistical overviews of reported outbreaks are published in the annual epidemiologic report on infectious diseases in April or May after the reporting year ( 15 ). Outbreaks of special interest are highlighted in short profiles in the weekly Epidemiological Bulletin, which may be followed by full outbreak reports in the same bulletin or other scientific journals ( 16 ). Outbreaks and Statistical Analyses Data presented in this article cover all outbreaks reported to the RKI from 2001 through December 2005 as of July 31, 2006. After the German infectious disease control law was passed, an outbreak was defined as >2 cases with an epidemiologic link ( 12 ). A case was considered epidemiologically confirmed if the clinical picture and an epidemiologic link to at least 1 laboratory-confirmed case was present as specified by the national case definition for the respective disease ( 17 ), e.g., a person with diarrhea and no laboratory diagnosis who had ingested the same implicated food item as >1 patients with laboratory confirmed salmonellosis. Outbreaks, which were part of a meta-outbreak, were not counted separately because the case data were already included in the respective meta-outbreak (Figure). Unless otherwise specified, analyses were limited to outbreaks caused by notifiable pathogens defined by the national surveillance case definitions ( 18 ). Duration of an outbreak was defined as the interval between the onset of the first and the last case of the outbreak. Date of diagnosis was used if date of onset was missing. Reporting delay between the different public health levels was based on the electronic time stamps for entering respective data into the database and arrival at the RKI. Reporting delay was computed for the years 2002 through 2005, as technical constraints did not allow these analyses for the 2001 data. Chi-square testing was used to compare the proportion of outbreaks with food as a source for various pathogens. The system for documenting qualitative descriptions of the outbreaks has undergone major revisions over the years. Therefore, data on these details are presented only for the years 2004 and 2005, to ensure a consistent and comparable data structure. Microsoft SQL Server 2005 (Microsoft Corp., Redmond, WA, USA) was used for database management. For the descriptive statistics, we used Statistical Package for the Social Sciences (SPSS) 15.0 for Windows, Version 15.0/1 (SPSS Inc., Chicago, IL, USA). Results From January 2001 through December 2005, a total of 30,578 outbreaks associated with notifiable pathogens were reported to RKI. Of 1,340,487 cases of notifiable diseases reported to RKI during this period, 253,720 cases (19%) were part of a reported outbreak; the rest were reported as sporadic cases (Table 2). Of these outbreaks, 90% were caused by pathogens of the intestinal tract (e.g., Salmonella, norovirus, rotavirus, hepatitis A virus, enteropathogenic Escherichia coli, and Campylobacter), and 10% (3,201) were caused by influenza virus (713), Mycobacterium tuberculosis (637), measles virus (501), and others (1,350, by 47 notifiable pathogens) ( 12 ). The size of the outbreaks ranged from 2 to 527 cases. Table 3 shows the number and duration of outbreaks by size and pathogens and indicates that duration increases with the size of the outbreak. The longest median durations were observed in outbreaks caused by hepatitis A virus (22 days) and by M. tuberculosis (73 days). Table 2 Total number of cases and outbreaks of notifiable disease, 2001–2005, Germany Data point 2001 2002 2003 2004 2005 All Total no. reported cases 245,133 284,425 252,119 267,130 291,680 1,340,487 No. (%) cases as part of reported outbreaks 22,146 
(9.0) 67,498 
(23.7) 48,855 
(19.4) 58,204 (21.8) 57,017 
(19.5) 253,720 (18.9) No. outbreaks (any size) 3,981 6,914 6,261 6,340 7,082 30,578 No. (%) outbreaks with 5 cases 863 (21.7) 2,341 (33.9) 1,737 (27.7) 2,333 (36.8) 2,137 (30.2) 9,411 (30.8) Table 3 Size and median duration* of outbreaks by pathogen, 2001–2005, Germany Outbreak type, 
no. cases/median duration Size of outbreak 2 3 4 5 6–9 10–49 50–99 >100 All Salmonella 5,855/2 2,134/2 1,006/2 504/2 721/3 636/6 34/16 10/22.5 10,900/2 Norovirus 1,169/2 641/3 469/3 342/4 984/6 3,694/9 636/17 140/26 8,075/7 Rotavirus 2,570/3 941/4 425/6 176/7 396/8 532/13 28/29 2/49 5,070/4 Campylobacter 2,032/1 390/2 123/3 44/3 45/4 34/8 1/8 0 2,669/1 Mycobacterium tuberculosis 454/62.5 102/105 44/103 16/229.5 19/282 2/253.5 0 0 637/73 Influenza 420/2 163/3 67/3 19/6 17/5 25/15 2/38.5 0 713/3 Hepatitis A virus 227/18 102/22 42/23 33/44.5 32/51.5 7/106 1/77 1/106 445/22 Giardia 192/2.5 52/12.5 27/13 4/12 3/74 4/27 0 0 282/4 Salmonella paratyphi 13/2 3/20 0 0 0 1/40 0 0 17/4 Other 1,052/2 318/6 134/8 61/14 88/17 102/40 8/83.5 7/123 1,770/6 All pathogens 13,984/2 4,846/3 2,337/4 1,199/4 2,305/6 5,037/9 710/18 160/27 30,578/3 *Duration and median duration are given in full days. In addition to the 30,578 outbreaks associated with notifiable pathogens, 772 outbreaks were reported but not associated with any specific pathogen; 155 outbreaks were associated with pathogens that are not notifiable as single cases. Among these 155 outbreaks, 25 (16.8%) were associated with varicella-zoster virus, 26 (16.1%) Staphylococcus spp., 24 (15.5%) Sarcoptes scabiei, 16 (10.3%) coxsackie virus, 15 (9.7%) adenovirus (nonconjunctivitis), 11 (7.1%) Streptococcus spp., 10 (6.5%) astrovirus, and 28 (18.1%) outbreaks with 1 of 16 other pathogens. The distribution of these pathogens did not show any significant change over the years. The size, duration, and reporting delay for these different kinds of outbreaks are compared in Table 4. Table 4 Comparison among outbreaks, 2001–2005, Germany* Characteristic Linked to notifiable pathogens Linked to nonnotifiable pathogens No link to any specific pathogen No. outbreaks 30,578 155 772 Median duration, d 3 9 4 Median no. cases per outbreak (minimum, maximum) 3 (2,527) 8 (2,153) 10 (2,110) Median duration from report of first case until outbreak report filed at local health department, d 26,597 154 772 Median duration between filing of outbreak report at local health department until arrival of report at RKI, d 1 0 0 Median duration from report of first case until outbreak report arrives at RKI, d 2 2 3 *RKI, Robert Koch Institute. A location setting was reported for 9,946 outbreaks (33%). Of 10,008 listed items, the most frequently named categories were households (5,262; 53%), nursing homes (1,218; 12%), hospitals (1,248; 12%), and kindergartens (783; 8%) (Table 5). Table 5 Locations of outbreaks by pathogen, 2004 and 2005, Germany* Location     No. (%) Norovirus 
(n = 3,141) Salmonella spp. (n = 2,703) Rotavirus 
(n = 1,985) Campylobacter spp. (n = 1,005) Hepatitis A 
(n = 139) Others 
(n = 973) All 
(n = 9,946) Household 395 (13) 1,993 (73) 1,338 (67) 758 (75) 102 (72) 676 (69) 5,262 (53) Nursing home 1,040 (33) 24 (1) 136 (7) 5 (0) 0 (0) 13 (1) 1,218 (12) Kindergarten 368 (12) 61 (2) 290 (15) 7 (1) 9 (6) 48 (5) 783 (8) Hospital, laboratory 1,035 (33) 20 (1) 175 (9) 5 (0) 1 (1) 12 (1) 1,248 (12) Hotel, cruise ship 58 (2) 169 (6) 16 (1) 120 (12) 12 (8) 93 (9) 468 (5) Restaurant 72 (2) 258 (9) 1 (0) 48 (5) 3 (2) 10 (1) 392 (4) Other location 34 (1) 80 (3) 28 (1) 36 (4) 7 (5) 61 (6) 246 (2) School, university 34 (1) 18 (1) 0 7 (1) 8 (6) 20 (2) 87 (1) Special event, festival, etc. 24 (1) 55 (2) 4 (0) 9 (1) 0 6 (1) 98 (1) Work place 37 (1) 21 (1) 0 10 (1) 0 17 (2) 85 (1) Dormitory, military casern 56 (2) 9 (0) 9 (0) 1 (0) 0 11 (1) 86 (1) Bus/ train, etc. 2 (0) 5 (0) 0 4 (0) 0 2 (0) 13 (0) Prison 2 (0) 4 (0) 3 (0) 0 0 3 (0) 12 (0) Refugee camp 0 2 (0) 0 0 0 8 (1) 10 (0) Total number of listed items 3,157 (100) 2,719 (100) 2,000 (100) 1,010 (100) 142 (100) 980 (100) 10,008 (100) *Outbreaks may be reported in >1 location. In the 13,422 outbreaks reported in 2004 and 2005, at least 1 exposure associated with the outbreak was reported in 10,205 (76%) outbreaks, which added up to a total of 22,001 field entries (average 2.2 entries per outbreak). For 15,978 (66%) of these 24,208 field entries, an evidence category was provided by the reporting local health departments. The distribution of these categories is shown in Table 1. In 954 (9.3%) of all 10,205 outbreaks linked to a specific exposure, the evidence of this linkage was based on a statistically significant association in a case-control or cohort study. For the 2,195 outbreaks with >10 cases, this type of evidence was reported in 248 (11.3%) outbreaks, compared with 706 (8.8%) of the 7,998 outbreaks with 10 cases were statistically significant and associated with the outbreak through case-control or cohort studies. In 37% of the reported foodborne outbreaks in SurvNet, the reporting local health departments were able to associate a meal but not a specific food item with the outbreak. Similarly, Jones et al. have observed that most foodborne outbreak investigations in the United States did not identify a specific food item ( 10 ). Local health departments must be motivated to improve outbreak investigations to increase the validity of the information received through this system ( 29 ). In addition to intensifying training programs for the local public health service, RKI is currently developing support tools, such as predesigned electronic line lists of cases and decision-supporting algorithms, to be included in the SurvNet system. Additional training and support tools will assist local health department personnel in the use of epidemiologic methods for outbreak investigations. A new information technology structure will facilitate these additions and further improve the timeliness of the system. SurvNet has the advantage of being able to document complex multistate outbreaks of any cause. For example, SurvNet was able to capture an outbreak of 1,024 cases of epidemic conjunctivitis, which started within the German armed forces and spread to the civilian population throughout the country ( 30 ). Comparatively few of the reported outbreaks (3%) were linked to nonnotifiable pathogens or could not be linked to specific pathogens at all. However, this demonstrates that SurvNet is able to cover outbreaks caused by unknown or emerging infectious diseases. Outbreak surveillance of SurvNet has already provided valuable information for topics of public health relevance. By confirming and quantifying the increase of hospital-based norovirus outbreaks in recent years, SurvNet has contributed to the development of specific recommendations on how to prevent and control norovirus outbreaks in hospitals and nursing homes ( 31 – 33 ). In 2006, a sharp increase of norovirus outbreak reports was noted at RKI from reporting weeks 43 through 47. This led to a countrywide alert in the national weekly epidemiologic bulletin in week 48 and was subsequently echoed by an alert throughout Europe in the Eurosurveillance Weekly Journal 2 weeks later ( 34 – 35 ). Although our report cannot replace a surveillance system evaluation, some system attributes can be addressed. Over a period of 5 years, SurvNet has demonstrated the ability to collect and analyze a large number of outbreak reports in a federal administrative environment of 431 local health departments and 16 federal states in Germany with a total population of 82 million inhabitants. This fact already indicates that requirements of simplicity, acceptability, and stability appear to have been met. SurvNet also seems to compare favorably to other systems in timeliness and sensitivity. The ability of SurvNet to capture outbreaks with unidentified or new pathogens in a systematic way indicates its suitability for outbreak surveillance of emerging infectious diseases. Given the federal structure in Germany and its reflection in the SurvNet design, this system might also be a blueprint for other large national or international outbreak surveillance systems, particularly in the context of the new international health regulations. Supplementary Material Appendix Figure Screen shot of outbreak report in SurvNet. 1) List of smaller outbreaks forming part of the meta outbreak; 2) number of cases in each outbreak; 3) geographic setting; 4) evidence categories by which a food product (here meat) was found to be associated with the outbreak (here by detection of identical pathogen in food and patient); and 5) additional description of outbreak.
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            Tuberculosis in the elderly in Germany.

             L Fiebig,  B Hauer,  D Altmann (2011)
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              Sicherung des Behandlungserfolges bei Tuberkulose

              (2012)
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                Author and article information

                Journal
                1886
                122234
                European Journal of Microbiology and Immunology
                EuJMI
                Akadémiai Kiadó, co-published with Springer Science+Business Media B.V., Formerly Kluwer Academic Publishers B.V.
                2062-509X
                2062-8633
                1 December 2012
                : 2
                : 4
                : 287-291
                Affiliations
                [ 1 ] Robert Koch Institute, Berlin, Germany
                [ 2 ] Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Postfach 65 02 61, D-13302, Berlin, Germany
                Author notes
                [* ] +49-30-18-754-3328, +49-30-18-754-3341, HauerB@ 123456rki.de
                Article
                7
                10.1556/EuJMI.2.2012.4.7
                Categories
                Original Articles

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