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Based on our national outpatient sentinel surveillance, we have developed a novel approach to determine respiratory syncytial virus (RSV) epidemic seasons in Germany by using RSV positivity rate and its lower limit of 95% confidence interval. This method was evaluated retrospectively on nine RSV seasons, and it is also well-suited to describe off-season circulation of RSV in near real time as observed for seasons 2020/21 and 2021/22 during the COVID-19 pandemic. Prospective application is of crucial importance to enable timely actions for health service delivery and prevention.

Background The COVID-19 pandemic expanded the need for timely information on acute respiratory illness at population level. Aim We explored the potential of routine emergency department data for syndromic surveillance of acute respiratory illness in Germany. Methods We used routine attendance data from emergency departments, which continuously transferred data between week 10 2017 and 10 2021, with ICD-10 codes available for > 75% of attendances. Case definitions for acute respiratory infection (ARI), severe acute respiratory infection (SARI), influenza-like illness (ILI), respiratory syncytial virus infection (RSV) and COVID-19 were based on a combination of ICD-10 codes, and/or chief complaints, sometimes combined with information on hospitalisation and age. Results We included 1,372,958 attendances from eight emergency departments. The number of attendances dropped in March 2020 during the first COVID-19 pandemic wave, increased during summer, and declined again during the resurge of COVID-19 cases in autumn and winter of 2020/21. A pattern of seasonality of respiratory infections could be observed. By using different case definitions (i.e. for ARI, SARI, ILI, RSV) both the annual influenza seasons in the years 2017–2020 and the dynamics of the COVID-19 pandemic in 2020/21 were apparent. The absence of the 2020/21 influenza season was visible, parallel to the resurge of COVID-19 cases. SARI among ARI cases peaked in April–May 2020 (17%) and November 2020–January 2021 (14%). Conclusion Syndromic surveillance using routine emergency department data can potentially be used to monitor the trends, timing, duration, magnitude and severity of illness caused by respiratory viruses, including both influenza viruses and SARS-CoV-2.

German national surveillance data analysis shows that hospitalisation odds associated with Omicron lineage BA.1 or BA.2 infections are up to 80% lower than with Delta infection, primarily in ≥ 35-year-olds. Hospitalised vaccinated Omicron cases’ proportions (2.3% for both lineages) seemed lower than those of the unvaccinated (4.4% for both lineages). Independent of vaccination status, the hospitalisation frequency among cases with Delta seemed nearly threefold higher (8.3%) than with Omicron (3.0% for both lineages), suggesting that Omicron inherently causes less severe disease.

Background Internet‐based participatory surveillance systems, such as the German GrippeWeb, monitor the frequency of acute respiratory illnesses on population level. In order to interpret syndromic information better, we devised a microbiological feasibility study (GrippeWeb‐Plus) to test whether self‐collection of anterior nasal swabs is operationally possible, acceptable for participants and can yield valid data. Methods We recruited 103 GrippeWeb participants (73 adults and 30 children) and provided them with a kit, instructions and a questionnaire for each sample. In the first half of 2016, participants took an anterior nasal swab and sent it to the Robert Koch Institute whenever an acute respiratory illness occurred. Reporting of illnesses through the GrippeWeb platform continued as usual. We analysed swabs for the presence of human c‐myc‐DNA and 22 viral and bacterial pathogens. After the study, we sent participants an evaluation questionnaire. We analysed timeliness, completeness, acceptability and validity. Results One hundred and two participants submitted 225 analysable swabs. Ninety per cent of swabs were taken within 3 days of symptom onset. Eighty‐nine per cent of swabs had a corresponding reported illness in the GrippeWeb system. Ninety‐nine per cent of adults and 96% of children would be willing to participate in a self‐swabbing scheme for a longer period. All swabs contained c‐myc‐DNA. In 119 swabs, we identified any of 14 viruses but no bacteria. The positivity rate of influenza was similar to that in the German physician sentinel. Conclusion Self‐collection of anterior nasal swabs proofed to be feasible, was well accepted by participants, gave valid results and was an informative adjunct to syndromic data.

Im Rahmen der nationalen Influenzapandemieplanung wurden in Deutschland neben dem Meldewesen gemäß Infektionsschutzgesetz (IfSG) weitere Überwachungssysteme etabliert. Ziel dieser Systeme sind die Beschreibung, Analyse und Bewertung der Situation bei akuten respiratorischen Erkrankungen (ARE), die Identifikation der hauptsächlich zirkulierenden Atemwegserreger und die Beschreibung des zeitlichen Verlaufs. Seit Beginn der COVID-19-Pandemie wurden die Systeme erweitert, um auch Infektionen mit SARS-CoV‑2 erfassen zu können. In diesem Beitrag werden drei verschiedene Surveillance-Systeme für ARE vorgestellt: GrippeWeb, die Arbeitsgemeinschaft Influenza mit dem SEEDARE-Modul (Sentinel zur elektronischen Erfassung von Diagnosecodes) und das Krankenhaus-Sentinel ICOSARI (ICD-10-code-basierte Krankenhaus-Surveillance schwerer akuter respiratorischer Infektionen). Mit diesen Systemen können ARE auf Bevölkerungsebene, im ambulanten und im stationären Bereich überwacht werden. Zusammen mit dem Monitoring der Mortalität liefern sie wichtige Hinweise zur Häufigkeit verschieden schwerer Krankheitsverläufe in der Bevölkerung. Um die Systeme für SARS-CoV‑2 zu erweitern, waren nur wenige Anpassungen notwendig. Da die Falldefinitionen für ARE nicht geändert wurden, können in den beschriebenen Systemen historische Zeitreihen zum Vergleich herangezogen werden. Alle Systeme sind so aufgebaut, dass stabile und etablierte Bezugsgrößen für die Berechnung von wöchentlichen Anteilen und Raten zur Verfügung stehen. Dies ist eine wichtige Ergänzung zum Meldewesen gemäß IfSG, welches stark von Testkapazitäten und -strategien sowie veränderten Falldefinitionen abhängt. Die Surveillance-Systeme haben sich in der COVID-19-Pandemie auch im internationalen Vergleich als praktikabel und effizient erwiesen.

A zoonotic A/sw/H1avN1 1C.2.2 influenza virus infection was detected in a German child that presented with influenza-like illness, including high fever. There was a history of close contact with pigs 3 days before symptom onset. The child recovered within 3 days. No other transmissions were observed. Serological investigations of the virus isolate revealed cross-reactions with ferret antisera against influenza A(H1N1)pdm09 virus, indicating a closer antigenic relationship with A(H1N1)pdm09 than with the former seasonal H1N1 viruses.

Mitigation of the coronavirus disease (COVID-19) pandemic in Germany included school closures in early March 2020. After reopening in April, preventive measures were taken in schools. We analysed national surveillance system data on COVID-19 school outbreaks during different time periods. After reopening, smaller outbreaks (average: 2.2/week) occurred despite low incidence in the general population. School closures might have a detrimental effect on children and should be applied only cautiously and in combination with other measures.

Background The burden of influenza in primary care is difficult to assess, since most patients with symptoms of a respiratory infection are not tested. The case definition of “medically attended acute respiratory infection” (MAARI) in the German physician sentinel is sensitive; however, it requires modelling techniques to derive estimates of disease attributable to influenza and respiratory syncytial virus (RSV). Objectives The objective of this paper was to review and extend our previously published model in order to estimate the burden of RSV and the differential burden of the two influenza B lineages (Victoria, Yamagata) as well as both influenza A subtypes on primary care visits. Methods Data on MAARI and virological results of respiratory samples (virological sentinel) were available from 2010/11 until 2017/18. We updated the previously published generalized additive regression model to include RSV. Results We found that the proportion of MAARI due to RSV is substantial only in the 0‐1‐ and 2‐4‐year‐old age groups (0‐1 years old: median 7.5%, range 4.0%‐14.8%; 2‐4 years old: median 6.5%, range 4.0%‐10.3%); in the 0‐1 years old age group, RSV leads in almost all seasons to a higher burden than any influenza type or subtype, but this is reversed in the age group 2‐4 years old. Conclusions We succeeded in rearranging our previously published model on MAARI to incorporate RSV as well as the two influenza B lineages (Victoria, Yamagata) in the time period 2010 to 2018.

We used physician sentinel surveillance to identify 25 (7.7%) mild to severe infections with enterovirus D68 (EV-D68) in children and adults among 325 outpatients with acute respiratory infections in Germany during August-October 2014. Results suggested low-level circulation of enterovirus D68 in Germany. Viruses were characterized by sequencing viral protein (VP) 1 and VP4/VP2 genomic regions.

Background To reduce the burden of severe influenza, most industrialized countries target specific risk-groups with influenza vaccines, e.g. the elderly or individuals with comorbidities. Since children are the main spreaders, some countries have recently implemented childhood vaccination programs to reduce overall virus transmission and thereby influenza disease in the whole population. The introduction of childhood vaccination programs was often supported by modelling studies that predicted substantial incidence reductions. We developed a mathematical transmission model to examine the potential impact of childhood influenza vaccination in Germany, while also challenging established modelling assumptions. Methods We developed an age-stratified SEIR-type transmission model to reproduce the epidemic influenza seasons between 2003/04 and 2013/14. The model was built upon German population counts, contact patterns, and vaccination history and was fitted to seasonal data on influenza-attributable medically attended acute respiratory infections (I-MAARI) and strain distribution using Bayesian methods. As novelties we (i) implemented a stratified model structure enabling seasonal variability and (ii) deviated from the commonly assumed mass-action-principle by employing a phenomenological transmission rate. Results According to the model, by vaccinating primarily the elderly over ten seasons 4 million (95% prediction interval: 3.84 – 4.19) I-MAARI were prevented which corresponds to an 8.6% (8.3% – 8.9%) reduction compared to a no-vaccination scenario and a number-needed-to-vaccinate (NNV) to prevent one I-MAARI of 37.1 (35.5 – 38.7). Additional vaccination of 2-10 year-old children at 40% coverage would have led to an overall I-MAARI reduction of 17.8% (17.1 – 18.7%) mostly due to indirect effects with a NNV of 20.7 (19.6 – 21.6). When employing the traditional mass-action-principle, the model predicted a more than 3-fold higher I-MAARI reduction (55.6%) due to childhood vaccination. Conclusion In Germany, the introduction of routine childhood influenza vaccination could considerably reduce I-MAARI among all age-groups and improve the NNV. However, the predicted impact is much lower compared to previous studies, which is primarily caused by our phenomenological approach to modelling influenza virus transmission. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2344-6) contains supplementary material, which is available to authorized users.

Background The World Health Organization recommends early antiviral treatment for patients with severe influenza illness or those at increased risk for severe illness. Objectives The aim of this study was to determine the proportion of cases with laboratory-confirmed A(H1N1)pdm09 infection that have been treated with antivirals in Germany during the pandemic (H1N1) 2009 and to investigate factors associated with the use of antivirals. Methods We analyzed cases with laboratory-confirmed A(H1N1)pdm09 infection notified to national health authorities in Germany between week 29/2009 and week 17/2010 using multivariable logistic regression. Severity of disease was defined by pneumonia or death. Results and conclusions Of 160 804 cases with laboratory-confirmed A(H1N1)pdm09 infection, 22% were treated with antivirals. Cases with severe disease were more likely to be treated with antivirals than cases without severe disease (odds ratio = 1·66; 95% confidence interval: 1·46–1·89). In the group with at least one underlying medical condition, only children aged between 1 and 4 years had significant lower odds for receiving antiviral treatment compared with cases in the age group 15 to 49 years (odds ratio = 0·75; 95% confidence interval: 0·6–0·94). In conclusion, the implementation of international recommendations on use of antivirals differed according to the age of patients in Germany during the pandemic (H1N1) 2009. This indicates that the potential of antivirals to prevent severe influenza might not have been fully exhausted. The reasons leading to the observed differences in patient management need to be investigated.

Every year epidemic waves of influenza and other acute respiratory infections (ARIs) cause a highly variable burden of disease in the population. Thus, assessment of the situation and adaptation of prevention strategies have to rely on real time syndromic surveillance.We have established an ICD-10-based electronic system allowing rapid capture and transmission of information on ARI (SEEDConsultations and ICD10-codes (J00-J22, J44.0 and B34.9) between week 16 in 2009, and week 15 in 2013, were used for comparison with AGI data. The time course and the correlation of weekly estimates of the incidence of medically attended ARI (MAARI) and ARI/100 consultations were analyzed for the different surveillance systems.The number of participating medical practices in SEEDWe conclude that SEED

Background Syndromic surveillance of severe acute respiratory infections (SARI) is important to assess seriousness of disease as recommended by WHO for influenza. In 2015 the Robert Koch Institute (RKI) started to collaborate with a private hospital network to develop a SARI surveillance system using case-based data on ICD-10 codes. This first-time description of the system shows its application to the analysis of five influenza seasons. Methods Since week 40/2015, weekly updated anonymized data on discharged patients overall and on patients with respiratory illness including ICD-10 codes of primary and secondary diagnoses are transferred from the network data center to RKI. Retrospective datasets were also provided. Our descriptive analysis is based on data of 47 sentinel hospitals collected between weeks 1/2012 to 20/2016. We applied three different SARI case definitions (CD) based on ICD-10 codes for discharge diagnoses of respiratory tract infections (J09 - J22): basic CD (BCD), using only primary diagnoses; sensitive CD (SCD), using primary and secondary diagnoses; timely CD (TCD), using only primary diagnoses of patients hospitalized up to one week. We compared the CD with regard to severity, age distribution and timeliness and with results from the national primary care sentinel system. Results The 47 sentinel hospitals covered 3.6% of patients discharged from all German hospitals in 2013. The SCD comprised 2.2 times patients as the BCD, and 3.6 times as many as the TCD. Time course of SARI cases corresponded well to results from primary care surveillance and influenza virus circulation. The patients fulfilling the TCD had been completely reported after 3 weeks, which was fastest among the CD. The proportion of SARI cases among patients was highest in the youngest age group of below 5-year-olds. However, the age group 60 years and above contributed most SARI cases. This was irrespective of the CD used. Conclusions In general, available data and the implemented reporting system are appropriate to provide timely and reliable information on SARI in inpatients in Germany. Our ICD-10-based approach proved to be useful for fulfilling requirements for SARI surveillance. The exploratory approach gave valuable insights in data structure and emphasized the advantages of different CD.

Estimation of the number of deaths as a consequence of the influenza pandemics in the twentieth and twenty-first centuries (i.e. 1918-1919, 1957-1958, 1968-1970 and 2009) is a challenge worldwide and also in Germany. After conducting a systematic literature search complemented by our own calculations, values and estimates for all four pandemics were collated and evaluated.A systematic literature search including the terms death, mortality, pandemic, epidemic, Germany, 1918, 1957, 1968, 2009 was performed. Hits were reviewed by title and abstract and selected for possible relevance. We derived our own estimates using excess mortality calculations, which estimate the mortality exceeding that to be expected. All identified values were evaluated by methodology and quality of the database. Numbers of pandemic deaths were used to calculate case fatality rates and were compared with global values provided by the World Health Organization.For the pandemic 1918-1919 we identified 5 relevant publications, 3 for the pandemics 1957-1958 and 1968-1970 and 3 for 2009. For all four pandemics the most plausible estimations were based on time series analyses, taken either from the literature or from our own calculations based on monthly or weekly all cause death statistics. For the four pandemics these estimates were in chronological order 426,600 (1918-1919), 29,100 (1957-1958), 46,900 (1968-1970) and 350 (2009) excess pandemic-related deaths. This translates to an excess mortality ranging between 691 per 100,000 (0.69 % in 1918-1919) and 0.43 per 100,000 (0.00043 % in 2009). Case fatality rates showed good agreement with global estimates.We have proposed plausible estimates of pandemic-related excess number of deaths for the last four pandemics as well as excess mortality in Germany. The heterogeneity among pandemics is large with a variation factor of more than 1000. Possible explanations include characteristics of the virus or host (immunity), social conditions, status of the healthcare system and medical advances.

Improvement is needed in preventing severe disease and nosocomial transmission in children beyond pandemic situations., We conducted a nationwide hospital-based prospective study in Germany of influenza A(H1N1)pdm09 cases among children

To minimize risks from pathogenic prion proteins, particular tissues from bovines and other ruminants have been declared specified risk materials (SRMs), which are required to be removed from the food chain. However, in particular for the sympathetic trunk (ST) as a part of the autonomous nervous system (ANS), which represents a potential transfer route for abnormal prion proteins (PrP(Sc)), this is not the case. Consequently, its destination during cutting procedures deserves attention. In this survey, the handling of the ST in beef cutting plants was recorded during ongoing work. To ease these observations, the ST was separated into five parts, and eight destinations for cuts were identified. By means of an observation sheet, the destination of the respective tissue was recorded. About one-third of the ST went into human consumption, another one-third was disposed of as SRMs, and the last one-third was used for nonfood purposes or disposed of. The rear thoracic and sacral ganglia primarily remained naturally connected to the bones going as SRMs. The stellate, front thoracic, and lumbar ganglia went in a different percent into the food chain. Frequently, workers in the same plant decided differently, even from case to case, on the destination of the tissue, which indicates a lack of standardization.

In March 2011, the German sentinel surveillance system for influenza (Arbeitsgemeinschaft Influenza (AGI)) was complemented by an Internet-based syndromic monitoring system (GrippeWeb) for acute respiratory infections (ARI) and influenza-like-illness (ILI). To assess representativeness of GrippeWeb participants, key demographic variables and lifetime prevalence of asthma and diabetes were compared with data from the general population of Germany. To 'validate' GrippeWeb, we compared weekly ARI and medically attended ARI (MAARI) rates, generated between weeks 35/2011 and 34/2012, with AGI MAARI rates and overlaid GrippeWeb ILI rates with the number of positive influenza samples obtained by the AGI. GrippeWeb had high weekly participation rates (62% of participants reported in ≥90% of possible weeks). Although it varied by age group, participants reported a mean of between 1.3 and 6.0 ARI episodes and between 0.1 and 2.4 ILI episodes during the study year. Estimated GrippeWeb MAARI incidence was very similar to the AGI MAARI incidence and influenza circulation was reflected well in the GrippeWeb ILI rates. GrippeWeb became a reliable monitoring system shortly after implementation, capturing the burden of ARI and ILI at general population level. The high degree of agreement between GrippeWeb's and AGI's MAARI data lends support to the validity of both systems. .

BACKGROUND: The number of patients seeking health care is a central indicator that may serve several different purposes: (1) as a proxy for the impact on the burden of the primary care system; (2) as a starting point to estimate the number of persons ill with influenza; (3) as the denominator data for the calculation of case fatality rate and the proportion hospitalized (severity indicators); (4) for economic calculations. In addition, reliable estimates of burden of disease and on the health care system are essential to communicate the impact of influenza to health care professionals, public health professionals and to the public. METHODOLOGY/PRINCIPAL FINDINGS: Using German syndromic surveillance data, we have developed a novel approach to describe the seasonal variation of medically attended acute respiratory infections (MAARI) and estimate the excess MAARI attributable to influenza. The weekly excess inside a period of influenza circulation is estimated as the difference between the actual MAARI and a MAARI-baseline, which is established using a cyclic regression model for counts. As a result, we estimated the highest ARI burden within the last 10 years for the influenza season 2004/05 with an excess of 7.5 million outpatient visits (CI95% 6.8-8.0). In contrast, the pandemic wave 2009 accounted for one third of this burden with an excess of 2.4 million (CI95% 1.9-2.8). Estimates can be produced for different age groups, different geographic regions in Germany and also in real time during the influenza waves.

INTRODUCTION: To establish strategic priorities for the German national public health institute (RKI) and guide the institute's mid-term strategic decisions, we prioritized infectious pathogens in accordance with their importance for national surveillance and epidemiological research. METHODS: We used the Delphi process with internal (RKI) and external experts and a metric-consensus approach to score pathogens according to ten three-tiered criteria. Additional experts were invited to weight each criterion, leading to the calculation of a median weight by which each score was multiplied. We ranked the pathogens according to the total weighted score and divided them into four priority groups. RESULTS: 127 pathogens were scored. Eighty-six experts participated in the weighting; "Case fatality rate" was rated as the most important criterion. Twenty-six pathogens were ranked in the highest priority group; among those were pathogens with internationally recognised importance (e.g., Human Immunodeficiency Virus, Mycobacterium tuberculosis, Influenza virus, Hepatitis C virus, Neisseria meningitides), pathogens frequently causing large outbreaks (e.g., Campylobacter spp.), and nosocomial pathogens associated with antimicrobial resistance. Other pathogens in the highest priority group included Helicobacter pylori, Respiratory Syncytial Virus, Varicella zoster virus and Hantavirus. DISCUSSION: While several pathogens from the highest priority group already have a high profile in national and international health policy documents, high scores for other pathogens (e.g., Helicobacter pylori, Respiratory syncytial virus or Hantavirus) indicate a possible under-recognised importance within the current German public health framework. A process to strengthen respective surveillance systems and research has been started. The prioritization methodology has worked well; its modular structure makes it potentially useful for other settings. peerReviewed

The mortality in Germany caused by the 2009 pandemic influenza A(H1N1) seems to have been one of the lowest in Europe. We provide a detailed analysis of all 252 fatal cases of confirmed infection with the pandemic virus notified between 29 April 2009 and 31 March 2010. The overall mortality was 3.1 (95% confidence interval (CI): 2.7 to 3.5) per one million inhabitants. We observed an increase in the case fatality rate of notified cases over time; notified cases aged 60 years or older had the highest case fatality rate (2.16%; 95% CI: 1.61 to 2.83; odds ratio: 5.4; p

Background In Germany, the first outbreak of highly pathogenic avian influenza A/H5N1 occurred among wild birds on the island of Ruegen between February and April 2006. The aim of this study was to investigate the use of recommended protective measures and to measure H5N1-seroprevalence among personnel tasked with bird collection. Methods Inclusion criteria of our study were participation in collecting wild birds on Ruegen between February and March 2006. Study participants were asked to complete a questionnaire, and to provide blood samples. For evaluation of the use of protective measures, we developed a personal protective equipment (PPE)-score ranging between 0 and 9, where 9 corresponds to a consistent and complete use of PPE. Sera were tested by plaque neutralization (PN) and microneutralization (MN) assays. Reactive sera were reanalysed in the World Health Organization-Collaborating Centre (WHO-CC) using MN assay. Results Of the eligible personnel, consisting of firemen, government workers and veterinarians, 61% (97/154) participated in the study. Of those, 13% reported having always worn all PPE-devices during bird collection (PPE-score: 9). Adherence differed between firemen (mean PPE-score: 6.6) and government workers (mean PPE-score: 4.5; p = 0.006). The proportion of personnel always adherent to wearing PPE was lowest for masks (19%). Of the participants, 18% had received seasonal influenza vaccination prior to the outbreak. There were no reports of influenza-like illness. Five sera initially H5-reactive by PN assay were negative by WHO-CC confirmatory testing. Conclusion Gaps and variability in adherence demonstrate the risk of exposure to avian influenza under conditions of wild bird collection, and justify serological testing and regular training of task personnel.

During the autumn wave of the pandemic influenza virus A/(H1N1) 2009 (pIV) the German population was offered an AS03-adjuvanted vaccine. The authors compared results of two methods calculating the effectiveness of the vaccine (VE). The test-negative case-control method used data from virologic surveillance including influenza-positive and negative patients. An innovative case-series methodology explored data from all nationally reported laboratory-confirmed influenza cases. The proportion of reported cases occurring in vaccinees during an assumed unprotected phase after vaccination was compared with that occurring in vaccinees during their assumed protected phase. The test-negative case-control method included 1,749 pIV cases and 2,087 influenza test-negative individuals of whom 6 (0.3%) and 36 (1.7%), respectively, were vaccinated. The case series method included data from 73,280 cases. VE in the two methods was 79% (95% confidence interval (CI) = 35-93%; P = 0.007) and 87% (95% CI = 78-92%; P