Effekte der Masern-Mumps-Röteln (MMR)-Impfung auf die Epidemiologie von Mumps in Deutschland

Mumps is an acute viral infectious disease characterized by fever and swelling and tenderness of one or more salivary glands, usually the parotid gland. Since 1976, the German Standing Committee on Vaccination (STIKO) has recommended a mumps vaccination as part of the routine immunization schedule in former West Germany. In East Germany, the vaccination was only introduced in 1991 after reunification. In the preceding decades, no comprehensive surveillance system existed in Germany. However, for East Germany and the successional federal states of former East Germany, data on mumps incidence are available from different Eastern surveillance systems for the time period 1968–2012. According to these data, the incidence of mumps has dropped from >?200 cases/100,000 annually in the pre-vaccine era to currently <1/100,000. Recently, an age shift has been noted predominantly in the Western federal states. Based on data from school entry examinations and seroprevalence studies, the age shift is likely due to insufficient vaccination coverage and secondary vaccine failure (“waning immunity”). In view of the changes in mumps epidemiology and the increase of outbreaks among adolescents and young adults, the implementation of a nationwide mandatory notification was initiated and came into effect in March 2013. Mandatory notification enables the early detection of outbreaks and obtainment of comprehensive data for evaluation of the immunization program in place. Regarding the long-term prevention of mumps in Germany, it is hoped that—as part of the measles and rubella elimination effort—coverage rates for the second MMR dose among children will increase nationwide above 95% and existing vaccination gaps among adults will be closed.     

Entwicklung der Herz-Kreislauf-Morbidität und -Mortalität in Ostdeutschland nach der politisch-ökonomischen Wende

Cardiovascular mortality decreased in the GDR between 1980 and 1989 in men by 14 % and in women by 18 %. In 1990, however, among men as well as women the rates increased considerably, particularly for the age group 25-44 (18 % and 17 %, respectively), but also for the age group 45-64 (7 % for both sexes). Compared with the mortality rates of 1989 this increase resulted in an excess-mortality of approximately 1120 cardiovascular deaths in this age range in East Germany during the year of the reunification. The re-arrangement of the coding practice in this year is obviously not an explaination for this phenomenon. There were, on the other hand, very similar trends of the cardiovascular mortality and the myocardial infarction and stroke morbidity in the years before and after the reunification. The stroke morbidity developed quite parallel with the hypertension prevalence rates. But we observed no relationship between the trends in hypercholesterolemia and smoking, on the one hand, and the myocardial infarction attack rates, on the other hand. However, the prevalence of psychosocial risk factors (social network, job stress, life events) increased considerably. This fact seems to play an important role particularly in the increase of the incidence of myocardial infarctions after the political change. Cardiovascular mortality droped after the reunification to a faster rate than before the reunification especially in the age range below 65 years. Nevertheless, cardiovascular mortality is still currently much higher in East than in West Germany. Therefore, in order to bring the East German rates in line with the West German rates it will probably still take a long time.     

Time trends in exposure to environmental tobacco smoke and parental educational level for 6-year-old children in Germany

The aim of the study was to investigate the association between exposure to environmental tobacco smoke of 6-year-old children and parental educational level in Germany under the changing socioeconomic conditions after reunification. Logistic regression was used to examine the relationship between tobacco smoke exposure of children (current environmental tobacco smoke, maternal smoking during pregnancy, environmental tobacco smoke during the first 3 years of the child’s life) and the determinants parental educational level, time and region. In Germany, the risk of environmental tobacco smoke exposure among 6-year-old children was strongly associated with parental educational level (odds ratio: ≥2 ‘low’/‘middle’ versus ‘high’ parental educational level). In West Germany, environmental tobacco smoke exposure generally exhibited a decreasing trend of about 20%. In contrast, in East Germany the environmental tobacco smoke exposure was only decreasing for children of parents with higher education. The gap between low and high parental educational level with respect to current children’s tobacco smoke exposure has increased from 1991 to 2000 in East Germany. A considerable fresh increase of maternal smoking during pregnancy could be observed around 1991 in both parts of Germany. In East Germany, the transition from a socialist economic system to a market economy after reunification might in part explain the increased gap of tobacco smoke exposure between children of parents with lower and higher educational levels.     

Characteristics of children with diagnosed pertussis

In 1997 a significant increase in the incidence of pertussis in the ?ód? voivodship was noticed--the incidence increased from 3.32 in 1996 to 26.34. The aim of this work was the analysis of the course of pertussis in the ?ód? voivodeship. Epidemiological history was analysed of 331 children with diagnosed pertussis from the end of 1996 to February 1998. The diagnosis was made on the basis of clinical picture and passive haemagglutination reaction (PHR). The highest incidence occurred between September and November 1997 (196/331--59.2%). Children aged 7-15 years and toddlers constituted the most numerous groups (respectively: 60.7% and 24.5%). The majority of children with pertussis (83%) received four doses of DTP vaccine, according to the current vaccination schedule. Only 8.2% of children did not receive DTP vaccination or received only 1 or 2 doses. In the majority of properly vaccinated children (73.5%--202/275) the disease appeared mainly after 6-15 years from the last 4th dose of DTP vaccine. From the group of children with pertussis, 18.7% required hospitalisation--these were mainly neonates and children aged 2 and 3 years. The number of children who developed pertussis was highest in school age children after 6-15 years from the last dose of vaccine. The severity of the disease, evaluated on the basis of the percentage of hospitalisations, was highest in the youngest age groups. The laboratory methods used (PHR) are not sufficient for proper diagnosis of pertussis, and cannot provide epidemiological data to assess the incidence of the disease. Increasing number of pertussis cases requires a revision in the schedule of prophylactic vaccination.     

The status of vaccine preventable diseases in Germany

The European members of the World Health Assembly (WHO) adopted the goal of eliminating poliomyelitis by the year 2000 (certification 2003), tetanus of the newborn by 2005 and measles by 2007 (certification 2010). Regarding the reduction by 2010 diphtheria, hepatitis B, pertussis and rubella syndrome are in the foreground of discussions. As WHO-member Germany looks after these aims with growing acceptance, too. The current situation of the specific target illnesses is differentiated in the eastern and western part of Germany. While the final stage of certification for a polio-free region in the whole of Germany has been reached and there have only been single illnesses of diphtheria and tetanus for years, there are reported more than 5,000 illnesses of hepatitis B every year with an estimated number of unknown cases of at least 15,000 clinically manifested illnesses and a high age specific incidence rate for people who are 20-40 years old. The incidence rate in the eastern federal states is lower than in the western federal states owing to a smaller portion of endangered risk groups in the population. The trend on the whole is declining. Useful epidemiological data of measles and pertussis are currently only available in the eastern federal states of reunited Germany. To control measles a national intervention programme "measles, mumps, rubella" was started. The aim of this programme is to reduce the illnesses of measles in Germany from currently 50 to at first 5 illnesses per 100,000 inhabitants. In the eastern German federal states the situation is still better than in the western federal states. However, a permanent lower incidence rate of less than 1/100,000 inhabitants has not been reached after 1990. Pertussis is an example for the consequences of different vaccination strategies in East and West. The estimated illness rates in the western federal states are at 80-100/100,000 inhabitants. In the eastern federal states a continuous increase of incidence rates of more than 5 per 100,000 inhabitants has been noticed since 1991. For a permanent reduction of incidence rates of infectious diseases which are preventable by vaccination, provable high vaccination coverage and an effective epidemiological control are necessary.     

Epidemiology of pertussis in a West African community before and after introduction of a widespread vaccination program

The control of pertussis remains a worldwide concern. Little has been documented about its epidemiology in Africa. The authors have studied pertussis in a prospective cohort of children in a rural West African community over a 13-year period comprising time before and after introduction of a vaccination program. Children under age 15 years who were residents of the Niakhar study area in Senegal were followed prospectively between January 1984 and December 1996 for the occurrence of pertussis. Morbidity and mortality rates were extremely high before the launch of immunization. Crude incidence was 183 per 1,000 child-years at risk under age 5 years, with a 2.8% case-fatality rate. After the introduction of the vaccination program, overall incidence dropped rapidly and dramatically-by 27% after 3 years and 46% after 6 years. The decline in incidence involved all age groups but was most substantial in the group under age 5 years and was particularly pronounced in unvaccinated infants. The median age of acquisition of the disease rose steadily with population vaccine coverage. This study shows the tremendous magnitude of the disease burden in children and the rapid decline after vaccination, and it suggests a strong herd-immunity effect.     

Pertussis after end of a mass vaccination project--end of the "vaccination honey-moon"

After 16 years of no vaccination against pertussis in Sweden, mass vaccination of infants and catch-up vaccination of children up to 10 years with a monocomponent pertussis toxoid vaccine was performed in the Greater Gothenburg area of Sweden between 1995 and 1999. At the end of the project in February 1999, 56% of all 10 year old children born in the Greater Gothenburg area had received 3 doses of the pertussis toxoid. No booster doses were given. This led to a temporary almost complete elimination of the disease. The aim of the present study was to follow the incidence of pertussis after end of the mass vaccination project (1999-2009) as it is reflected by laboratory verified cases (cultures and/or PCR) and pertussis hospitalizations. A reemergence of pertussis was seen from the end of 1999 with a peak in 2004 followed by a decrease when booster doses to both 6 and 10 year old children were introduced in 2005-2006. From July 1, 1999 through December 31, 2009 a total of 1973 cases were diagnosed with culture or PCR. The disease was prevalent in all age groups. The highest documented incidence was seen in infants younger than 12 months. 450 patients with verified pertussis had received 3 doses of the pertussis toxoid vaccine in the mass vaccination project and some other trials (comprising a total of 69,423 children). The mean time from the last dose to the laboratory verification of pertussis was 5 years in these 450 cases. There were 128 hospitalizations, 106 of which were in infants. In conclusion, pertussis is still not eliminated from the area. Booster doses are needed but the numbers and optimal timing are not known.     

Regional variation and time trends in mortality from ischaemic heart disease: East and West Germany 10 years after reunification

STUDY OBJECTIVE: Within Europe, a pronounced geographical gradient of mortality from ischaemic heart disease has been observed with the highest burden in the north east and the lowest in the south west. The study objective was to compare mortality from ischaemic heart disease between former East and West Germany since reunification. DESIGN: Analyses of age standardised mortality rates from ischaemic heart disease (ICD-9 410-414, ICD-10 I20-I25) between 1990-1991 and 2000. SETTING: Former East and West Germany. MAIN RESULTS: After a peak in the early 1990s, mortality from ischaemic heart disease has substantially declined in both parts of Germany (from 222 to 169 per 100 000 in the East and from 150 to 116 per 100 000 in the West). The regional difference, however, remained rather constant: the rate ratio between the pooled mortality in the East compared with the West was 1.51 (95% CI 1.46 to 1.56) in 1991 and 1.45 (95% CI 1.39 to 1.50) in 2000. These rate ratios were higher in women (1.63 in 1991 and 1.52 in 2000) compared with men (1.45 and 1.44, respectively). CONCLUSIONS: Within Germany, there has been a pronounced east-west gradient of mortality from ischaemic heart disease since reunification. Further insight into possible underlying reasons may lead to improved preventive strategies.     

Pertussis in Poland

BACKGROUND: Since 1997, an unexpected 2-5-fold increase in the incidence of pertussis has been reported in Poland in comparison with the previous 10 years, although the introduction of the diphtheria-tetanus-pertussis (DTP) vaccination in 1960 reduced the incidence of pertussis approximately 100-fold in the 1980s. The aim of the study was to analyse all available data on pertussis in Poland to identify the risks associated with its re-emergence. METHODS: Available data on notification, incidence, mortality, hospitalization, geographical distribution, incidence according to age, and diagnosis of pertussis were collected from national surveillance monographs and statistically evaluated. RESULTS: Analyses performed in the study found two periods of rising and falling trends: in the incidence before and after 1989, respectively. Moreover, after 1989, the age-specific incidence among children aged 0-4 years decreased, and among 5-9, 10-14, and 15-19 year olds increased in comparison to the previous decade. The incidence rate of pertussis among infants was similar in both decades analysed. Clustering of pertussis incidence increase in provinces along a line from North East to South West was observed. CONCLUSIONS: As vaccination coverage did not decrease and diagnostics have not been improved since the 1980s, it is possible that waning immunity and the appearance of Bordetella pertussis vaccine escape mutants are involved in the changing pertussis epidemiological parameters. Further monitoring studies, together with improving diagnostics, might allow more precise epidemiological data to be obtained. An additional booster dose of acellular pertussis vaccine at age 6 years has been included in the current vaccination schedule.     

Cost-effectiveness of adult pertussis vaccination in Germany

BACKGROUND: The incidence of pertussis in adults is high despite good childhood vaccination coverage. An adult formulation of an acellular pertussis vaccine is licensed and available for use in Germany. OBJECTIVE: To evaluate the potential health benefits, risks, costs and cost-effectiveness of routine pertussis vaccination programs for German adults. METHODS: A Markov model was used to simulate health states and immunity levels associated with pertussis disease and vaccination. The following strategies were evaluated: (1) no adult pertussis vaccination, (2) one-time adult vaccination at 20-64 years, and (3) adult vaccination with decennial boosters. Our main outcome measures were costs (2006 Euros), cases prevented, incremental cost per case prevented and incremental cost per quality-adjusted life year (QALY) saved. We performed sensitivity analyses for key assumptions in the model including disease incidence, vaccine cost, vaccine efficacy, disease costs and frequency of adverse events. Future costs and benefits were discounted at 3%. RESULTS: At a disease incidence of 165 per 100,000, the one-time adult vaccination strategy would prevent 498,000 cases, and the decennial adult vaccination strategy would prevent 1 million cases. Approximately 31 million adults ( approximately 62% of the cohort) would be vaccinated with a one-time adult vaccination strategy for a total program cost of 366 million Euros, while a decennial vaccination strategy would cost 687 million Euros. The one-time adult vaccination strategy resulted in CE ratios of 5800 Euros per QALY saved, or 160 Euros per pertussis case prevented. The decennial booster strategy cost 7200 Euros per QALY saved, or 200 Euros per case prevented. The results were most sensitive to assumptions about disease incidence and vaccine cost. CONCLUSIONS: Routine vaccination of German adults aged 20-64 years with Tdap is cost-effective.     

The seroepidemiology of Bordetella pertussis infection in Western Europe

High titres of pertussis toxin (PT) antibody have been shown to be predictive of recent infection with Bordetella pertussis. The seroprevalence of standardized anti-PT antibody was determined in six Western European countries between 1994 and 1998 and related to historical surveillance and vaccine programme data. Standardized anti-PT titres were calculated for a series of whole-cell and acellular pertussis vaccine trials. For the serological surveys, high-titre sera (> 125 units/ml) were distributed throughout all age groups in both high- (> 90%) and low-coverage (< 90%) countries. High-titre sera were more likely in infants in countries using high-titre-producing vaccines in their primary programme (Italy, 11.5%; Western Germany, 13.3%; France, 4.3%; Eastern Germany, 4.0%) compared to other countries (The Netherlands, 0.5%; Finland, 0%). Recent infection was significantly more likely in adolescents (10-19 years old) and adults in high-coverage countries (Finland, The Netherlands, France, East Germany), whereas infection was more likely in children (3-9 years old) than adolescents in low-coverage (< 90%; Italy, West Germany, United Kingdom) countries. The impact and role of programmatic changes introduced after these surveys aimed at protecting infants from severe disease by accelerating the primary schedule or vaccinating older children and adolescents with booster doses can be evaluated with this approach.     

Pertussis vaccination in infancy lowers the incidence of pertussis disease and the rate of hospitalisation after one and two doses: analyses of 10 years of pertussis surveillance

Objectives

Shortly after pertussis vaccination was reintroduced in Sweden in 1996, an intensified pertussis disease surveillance programme was set up. In this study, we report on in-depth analyses of age–dose–number-specific incidences and the rate of pertussis hospitalisation for children with no, 1 or 2 doses of an acellular pertussis vaccine before pertussis disease. Vaccine coverage, the timeliness of childhood vaccination and the effect of later than scheduled pertussis vaccination(s) are also examined.

Study design

Children with notified laboratory-confirmed (culture or PCR) pertussis disease were evaluated among the surveillance population of about 1 million infants, born between 1996 and 2007 and followed for pertussis disease from October 1997 to December 2007, for nearly 6 million person-years. Birth and vaccination dates of the diseased children are known from the surveillance programme. To estimate denominators of the age–dose–number-specific pertussis incidences, we used birth and vaccination dates from a vaccine trial with more than 72,000 infants combined with national pertussis vaccine coverage data for children in the surveillance population.

Results

For infants from 3 to <5 months of age, the incidence of pertussis disease with at least 14 days of cough decreased from 264/100,000 for unvaccinated infants to 155/100,000 for infants with one dose of a pertussis vaccine prior to onset of the disease. In the age range 5 to <12 months, the age–dose specific incidences were 526, 95, and 24/100,000 for infants with no, 1 and 2 doses, respectively. The rate of hospitalisation for infants with 1 dose of a pertussis vaccine prior to onset of the disease was significantly lower than for unvaccinated infants of the same age.For many infants, there is a delay in administration of the vaccine doses according to the regular 3–5–12 month schedule (which has been the case for many years). Hypothetically, if all infants had been vaccinated exactly on schedule, we would expect about 28% fewer pertussis cases with at least 14 days of cough and 38% fewer hospitalisations due to pertussis, of cases possible to influence by vaccinations on schedule.

Conclusion

Pertussis vaccination had a significant effect among infants already after the first dose. This is particularly important for premature infants and infants with severe respiratory and cardiac diseases. A moderate decrease in the incidence of pertussis disease in infants and rate of hospitalisation could be expected if primary vaccinations were carried out closer to the scheduled time than is currently the practice in Sweden.     

Accelerating control of pertussis in England and Wales

Results of an accelerated pertussis vaccination schedule for infants introduced in 1990 in England and Wales were examined. Earlier scheduling and sustained high vaccine coverage resulted in fewer reported cases of pertussis among infants, reinforcing the World Health Organization drive for on-time completion of the infant vaccination schedule. As determined by using the screening method, the first dose of vaccine was 61.7% effective in infants <6 months of age, and effectiveness increased with subsequent doses. Three doses of a good whole-cell pertussis vaccine were 83.7% effective in children 10-16 years of age; a preschool booster vaccination further reduced pertussis incidence in children <10 years of age. As in other industrialized countries, surveillance data during 1998-2009 showed that pertussis in England and Wales mainly persists in young infants (i.e., <3 months of age), teenagers, and adults. Future vaccine program changes may be beneficial, but additional detail is required to inform such decisions.     

Weight gain in two adult cohorts in East and West Germany reunification

BACKGROUND: Several epidemiological studies have shown consistently higher prevalence rates of obesity and overweight in East German adults compared to West German adults before German reunification in 1990. If different lifestyle factors after German division contribute to these differences, one might speculate that trends of obesity and overweight in the East and West after German reunification in 1990 would be similar. OBJECTIVE: To examine weight gain in East and West German adult cohorts in the decade after German reunification. METHODS: The study population includes 554 individuals with complete data aged 20 - 47 years in 1990-92 participating in the ten year follow-up of the European Community Respiratory Health Survey (ECRHS) in the German centres Hamburg (West) and Erfurt (East). Age and occupation-adjusted prevalence and incidence rates, stratified for gender and centre, were calculated for the Erfurt and Hamburg cohorts. RESULTS: The prevalence of overweight increased in males and females in both cities, and was statistically significant for Hamburg males (32.7% to 44.9%), Hamburg females (12.3% to 25.4%) and Erfurt females (18.5% to 31.2%). The increase in the prevalence of obesity was statistically significant for males (Hamburg: 3.7% to 7.9%; Erfurt: 5.2% to 10.8%) and for females only in Hamburg (6.4% to 14.2%). The increase in the prevalence of overweight and obesity were larger in Hamburg than in Erfurt. Moreover, the incidence rates of obesity were higher in Hamburg for both sexes, but were not statistically significant CONCLUSION: Our findings indicate different patterns of weight gain in 2 study sites in East- and West-Germany. These results might reflect a convergence of initially higher prevalences of overweight and obesity in the East with initially lower prevalences in the West.     

Mumps in Poland in 2000

A total of 17,548 mumps cases were reported in Poland in 2000. A 5-fold decrease in incidence of the disease (from 233.4 to 45.4 per 100,000 population) was noted, when compared with 1999. Approximately 4.8% of mumps cases were hospitalized (849 cases). The majority of the reported cases were children aged 5-9 (51.4% of all cases). In all voivodships the incidence was lower than in previous years. The probable cause of the decline of mumps cases was a marked amelioration of MMR vaccination coverage among 3-year old children. The MMR vaccine is not included into the national program of immunization, the vaccination is recommended for 2-year and 7-year old children.     

Re-emergence of pertussis in Slovenia: time to change immunization policy

The introduction of childhood vaccination has dramatically reduced morbidity and mortality of pertussis in Slovenia. However, despite high vaccination coverage for many decades, reported incidence has increased recently, to the highest incidence of 27.5/100,000 in 2006, a 6.5-times increase in comparison to the previous year. Marked shift in age distribution among reported cases was observed in recent years. In 2006, reported age-specific incidence was relatively high in children 8-12 years old, the highest among 9 years old. Similar to other countries, where children are given pre-school boosters, we also have to consider the revision of the national vaccination policy. A booster dose at school entrance or latest at 8 years of age should be introduced to decrease the transmission of disease among school children and to further reduce the burden of disease among infants.     

Violence and fear of violence in East and West Germany

The purpose of this research was to assess the effect of major social changes in Germany since 1989 on mortality due to intentional injury. Mechanisms and types of fatal intentional injury in East and West Germany between 1970 and 1995 were determined from death certificates and compared with judicial data on violent crime convictions and recent public survey data on citizen fear of crime. The number of homicides among East German males increased between 1989 and 1991, and the homicide rate remains high when compared with West German males (although lower than that of American males). Homicide among German females is less common, presently about equally likely in East and West. Violent crime in general has become more frequent in Germany, and citizen fear of crime has increased markedly, especially in the East. Non-citizens are convicted for an increasing number of homicides and assaults. Rates of suicide were declining in East and West before reunification, and these rates have continued to decline. Social changes in Europe since 1989 have led to noticeable increases in violence and homicide in Germany, which in turn have reduced feelings of security among German citizens, especially in the East. Suicide rates have not been affected.     

Injury mortality in East Germany

OBJECTIVES: This study determined the effects of social changes in East Germany since 1989 on patterns of injury mortality. METHODS: Death certificate data regarding injuries from 1980 through 1995 and police data regarding traffic injuries in East Germany from 1980 through 1998 were compared with similar data from West Germany. RESULTS: The number of motor vehicle-related injuries and deaths in East Germany increased dramatically between 1989 and 1991, whereas those in West Germany declined slightly. The increased mortality in the more rural East has especially involved young men driving automobiles on rural roads and has persisted since reunification of East and West Germany. Falls, other accidents, and suicides have shown no such effect. Homicide among East German men has increased but remains uncommon. CONCLUSIONS: Recent social changes in East Germany, including increased access to motor vehicles and decreased restrictions on personal freedom, have been associated with increased motor vehicle crashes and mortality, especially among young men and on rural roads.     

A big pertussis outbreak in a primary school with high vaccination coverage in northern China: An evidence of the emerging of the disease in China

BackgroundA big pertussis outbreak occurred in a primary school with high vaccination coverage in northern China. An investigation was carried out in order to calculate the attack rate and identify the risk factors.MethodsBetween May 12 and July 29, an investigation was carried out in the primary school, which included 383 students and 27 teachers. Three definitions were used to distinguish the cases: confirmed, epidemiologically linked and suspected cases. A total of 232 blood samples were collected and examined by ELISA among healthy children in another primary school.ResultsA total of 138 suspected pertussis cases were counted, of which 116 students were confirmed. The attack rate among students was as high as 30.29%. The pertussis outbreak lasted 88 days, and had quaternary cases of transmission. Migrant children were almost four times as likely to catch the disease as local children (p = 0.005). In addition, students who had received the last dose of pertussis vaccine more than 4 years prior were three times more likely of becoming ill than those less than 4 years (p = 0.006). The average level of antibodies to pertussis was 30.99 IU/mL among healthy children. No statistically significant difference was observed between DTaP and DTwP (p = 0.843).ConclusionsThis pertussis outbreak in a primary school with high vaccination coverage was an evidence of the pertussis resurgence in China. The major risk factor we identified was the waning of immunity in the years after pertussis vaccination. Booster vaccination for students should be given.