Infectious diseases before and after German unification: trends in mortality and morbidity

After the fall of the Berlin Wall in 1989 the former communist countries of central and eastern Europe underwent substantial social and economic changes that had a major impact on health. The situation of the former German Democratic Republic was unique in that its existing institutions were replaced rapidly and it was quickly integrated economically with the West. This study describes recent trends in morbidity and mortality from infectious diseases in East and West Germany before and after unification using routine data from 1980 onwards. Substantial differences in morbidity and mortality resulting from infectious diseases were observed between East and West Germany. These seem to be the complex result of societal and health system differences in both parts of Germany before unification, differing population dynamics and health behaviours, and an increasing westernisation in the eastern part of Germany during recent years.     

AIDS – Wie leben schwule Männer heute? Kurzfassung der Ergebnisse der Befragung November 1999

A four page questionnaire was included in the November 1999 edition of 10 monthly German magazines for gay men to investigate how this population responds to risks posed by HIV/AIDS. This was the sixth time the questionnaire was administered in the former West Germany since 1987 and the fourth time in the former East Germany since 1991. A total of 2995 men responded (16% from the former East Germany, and 84% from the former West Germany). In 1999, 72% of respondents from both the western and eastern parts of the country did not engage in risk contacts in the twelve months preceding the survey, where risk contact was defined as unprotected anal intercourse with partners whose serostatus was unknown or whose status differed from that of the subject. In 1996, this percentage was 72% for East Germans and 76% for West Germans. The occurrence of protective behaviour in East and West has become increasingly similar over time; whereas, the proportion of men in the West German samle taking risks has increased since 1996. Whether the increased risk-taking in the West can be attributed to the introduction of combination therapy is a question which cannot be answered on the basis of the data gathered.     

Is the prevalence of atopic diseases in East and West Germany already converging?

Studies comparing respiratory health of residents in the areas of former East and West Germany have shown higher rates of asthma and allergies in children and young adults in former West Germany. It has been speculated that some factors associated with western lifestyle may be related to higher rates of atopic diseases among residents of former West Germany. We examined if the prevalence rates of self-reported asthma and nasal allergies in adults converged between the areas of former East and West Germany five years after re-unification. During the years 1990–1992 and 1994–1995 two independently drawn random samples of more than 3,000 subjects between the ages of 20 to 44 years answered a screening questionnaire of the European Community Respiratory Health Survey in Erfurt (East Germany) and in Hamburg (West Germany). The prevalence rates of asthma attacks, asthma medication use, allergic rhinitis, and wheezing remained stable in Hamburg but increased significantly in Erfurt approaching those of Hamburg. The data indicate that there is a tendency for the prevalence rates of self-reported allergic rhinitis and asthma-related respiratory symptoms in the eastern part of Germany to increase to West-German levels. It is not yet clear if this is due to a true increase in morbidity or only to a higher awareness for these diseases among doctors and the public.     

Self rating of health is associated with stressful life events, social support and residency in East and West Berlin shortly after the fall of the wall

STUDY OBJECTIVE: To compare the health status and factors influencing the health of populations that had previously lived under different political systems. DESIGN: Cross sectional health and social survey using postal interviews. The relation between self reported health and psychosocial factors (stressful life events, social support, education, health promoting life style and health endangering behaviour) was investigated. To determine East-West differences a logistic regression model including interaction terms was fitted. SETTING: East and West Berlin shortly after reunification 1991. PARTICIPANTS: Representative sample of 4430 Berlin residents aged 18 years and over (response rate 63%). RESULTS: Of all respondents, 15.4% rated their health as unsatisfactory. Residents of East Berlin rated their health more frequently as unsatisfactory than residents of West Berlin (Or(age adjusted)= 1.29, 95%CI 1.08, 1.52), these differences occurred predominantly in the over 60 years age group. Logistic regression showed significant independent effects of stressful life events, social support, education, and health promoting life style on self rated health. The effects of education and health promoting life style were observed to be more pronounced in the western part of Berlin. Old age and female sex showed a stronger association with unsatisfactory health status in the eastern part of Berlin. CONCLUSIONS: For subjects aged over 60 years there was evidence that living in the former East Berlin had an adverse effect on health compared with West Berlin. The impact of education and a health promoting lifestyle on self rated health seemed to be weaker in a former socialist society compared with that of a Western democracy. This study supports an "additive model" rather than a "buffering model" in explaining the effects of psychosocial factors on health.     

The impact of maternal education on intrauterine growth: a comparison of former West and East Germany

BACKGROUND: Objective of this re-analysis of datasets from former East and West Germany was to examine the influence of maternal education on intrauterine growth in two different political and social systems. METHODS: Information on socio-demographic or lifestyle factors and pregnancy outcome was available for 3374 liveborn singletons from West Germany (1987/88) and 3070 from East Germany (1990/91). Multiple logistic regression was used to estimate the association between maternal education and the risk of delivering a small-for-gestational-age (SGA) newborn below the 10th percentile of birthweight. RESULTS: Women with the lowest education had a significantly elevated risk of SGA newborns compared to women with the highest education in West (odds ratio [OR] = 2.58, 95% CI : 1.17-5.67) and East Germany (OR = 2.77, 95% CI : 1.54- 5.00). The distribution of factors known to influence intrauterine growth varied with education in both states. After adjusting for these factors, women with the lowest educational level still had a higher risk of SGA birth: OR (West) = 2.02, 95% CI : 0.87-4.72; OR (East) = 1.95, 95% CI : 1.02-3.74. CONCLUSIONS: Our findings support the assumption that in former socialist countries health inequalities as a result of social inequalities existed.     

Changes in social inequality with respect to health-related living conditions of 6-year-old children in East Germany after re-unification

Background  

Since Germany re-unified in 1990, substantial social and economic changes have happened in East Germany, the former socialist German Democratic Republic (GDR). The aim of this study was to investigate the influence of these socio-economic changes in East Germany on the association between social status, measured by parental educational level, and health-related living conditions of children during the ten-year period after re-unification.     

Cross-sectional study on influenza vaccination,Germany, 1999-2000

To assess influenza vaccination coverage in Germany, we conducted a nationwide telephone survey in November 1999 in adults (>18 yrs) using random-digit dialing. Overall, 23% of 1,190 survey participants reported having been vaccinated (adjusted 18%) with 16% (adjusted 15%) in former West Germany versus 35% (adjusted 32%) in former East Germany. Immunization rates for vaccination target groups were lower in West Germany (21%) than in East Germany (40%). Seven percent of health-care workers were immunized. Previous influenza vaccination, positive attitudes towards immunization, and having a family physician increased the rate of vaccination; fear of adverse effects lowered the rate. Family physicians performed 93% of the vaccinations, which suggests their key role in improving low vaccination coverage in Germany. The fact that >71% (850/1,190) of participants belonged to at least one of the vaccination target groups recommended by the German Standing Commission on Immunization emphasizes the need to focus the definition of target groups.     

Two Types of Health Care Systems and Their Influence on the Introduction of Perinatal Care: An Epidemiological Twin Model in Berlin from 1950 to 1990

Objectives: When perinatal medicine emerged as a new medical discipline in the 1960s, Berlin was as one of the world's leading centers. During that time, the city was separated into two parts, each fostering its own health care system. After the destruction of the Berlin Wall, it was possible to speak with the citizens of East Berlin and to access their database systems. This created the singular opportunity to objectively compare the development of perinatal care in both parts of Berlin. Methods: Rates of maternal, perinatal, and infant mortality as well as the rate of preterm deliveries were evaluated over time and between East and West Berlin. The timing of introduction of 20 specific perinatal interventions was evaluated across 18 hospitals with more than 500 deliveries (11 in West Berlin and 7 in East Berlin). Interviews were conducted with 100 gynecologists, 100 midwives, and 100 women who had recently delivered their first child from each side of the city regarding their opinions of the importance of these interventions for the quality of perinatal medicine and how they would distribute a budget to improve maternity care. Results: Maternal, perinatal, and infant mortality decreased in both parts of Berlin until 1990 (p<0.0001), without significant differences between East and West Berlin, though the preterm delivery rate was slightly lower in East Berlin compared with West Berlin (p<0.06). Some new clinical techniques and treatments—such as cardiotocography, ultrasound, tocolytic therapy, and peridural anesthesia—were introduced earlier in West Berlin. In contrast, certain public health measures—such as maternal transport, screening programs for diabetes, and support of breastfeeding—were introduced much earlier in East Berlin. There were significant differences between the beliefs of gynecologists, midwives, and mothers in East and West Berlin. In general, citizens of East Berlin were more enthusiastic about technological medical advances, whereas citizens of West Berlin were more supportive of public health and alternative methods. In addition, there were significant differences between female and male physicians in their beliefs about how to improve health care, regardless of whether they resided in East or West Berlin. Conclusions: The results of this study may serve as a basis for reflection on how different social circumstances and health care policies can influence the improvement of maternal and child health care.     

Low birth weight in Germany 1990–92

Summary. The reunification in 1990 of the German Democratic Republic (GDR) and the Federal Republic of Germany (FRG) produced profound social transformations. Changes in the distribution of low birth-weight (LBW, < 2500 g) in the two parts of the country between 1990 and 1992 have been studied by analysing vital statistics for the period. In absolute numbers, livebirths in the former FRG remained stable, while those in the former GDR declined by 51%. Numbers of LBW livebirths increased slightly in the former FRG and decreased in the former GDR; those in the category between 500 and 999 g remained stable in the former GDR and increased in the former FRG. However in terms of proportion, livebirths in this category doubled in the former GDR. Migration rates for the same period showed a shifting population from East to West particularly of young people, and maternal age-specific numbers of livebirths decreased in both countries. Psychosocial stress may have contributed to the rise in ELBW, but it is also possible that the improvement and sharing of perinatal management strategies may have led to increased survival of babies < 1000g. Most importantly, the observed rise in the proportion of ELBW births (except those < 500 g) could be a result of the introduction of the more comprehensive definition of livebirth into the former GDR.     

Twenty years of the German Environmental Survey (GerES): human biomonitoring--temporal and spatial (West Germany/East Germany) differences in population exposure

The German Environmental Surveys (GerESs) are nationwide population studies, which have repeatedly been carried out in Germany since the mid-1980s. The subjects were representatively selected from the regional registration offices with regard to age, gender and community size. The first survey for adults (GerES I) was carried out in 1985/1986 (West Germany) followed by GerES IIa in 1990/1991 (West Germany) and GerES IIb in 1991/1992 (East Germany). In GerES II children were also included to some extent. In 1998, the third GerES for adults was conducted in both parts of Germany (GerES III). The current survey 2003/2006 (GerES IV) is focussing exclusively on children. A 1-year pilot study was conducted in 2001-2002 to collect information on parameters influencing the response rate and to test the suitability of the different instruments intended to be used for the main study. The main goal of the surveys is to analyse and document the extent, distribution and determinants of exposure to environmental pollutants of the German general population. Three main instruments of investigation were comprised in GerES: human biomonitoring (HBM), monitoring of the domestic environment, and collecting information on exposure pathways and living conditions via questionnaires. This paper is focussed on the general design of the GerESs, the trend over time and spatial differences (West Germany and East Germany) for HBM data on arsenic, cadmium, lead, mercury, pentachlorophenol (PCP), and polycyclic aromatic hydrocarbons (PAH). These substances have been determined in blood and/or morning urine of adults and children. All GerESs have been conducted in close connection with the National Health Interview and Examination Surveys performed by the Robert Koch-Institute, Berlin.     

Changing mortality patterns in East and West Germany and Poland. II: short-term trends during transition and in the 1990s

OBJECTIVES: To examine trends in life expectancy at birth and age and cause specific patterns of mortality in the former German Democratic Republic (GDR) and Poland during political transition and throughout the 1990s in both parts of Germany and in Poland. METHODS: Decomposition of life expectancy by age and cause of death. Changes in life expectancy during transition by cause of death were examined using data for 1988/89 and 1990/91 for the former GDR and Poland; examination of life expectancy changes after transition were based on 1992-97 data for Germany and 1991-96 data for Poland. RESULTS: In both the former GDR and Poland male life expectancy at birth declined by almost one year during transition, mainly attributable to rising death rates from external causes and circulatory diseases. Female life expectancy in Poland deteriorated by 0.3 years, largely attributable to increasing circulatory mortality among the old, while in East German female rising death rates in children and young adults were nearly outbalanced by declining circulatory mortality among those over 70. Between 1991/92 and 1996/97, male life expectancy at birth increased by 2.4 years in the former GDR, 1.2 years in old Federal Republic, and 2.0 years in Poland (women: 2.3, 0.9, and 1.2 years). In East Germany and Poland, the overall improvement was largely attributable to falling mortality among men aged 40-64, while those over 65 contributed the largest proportion to life expectancy gains in women. The change in deaths among men aged 15-39 accounted for 0.4 of a year to life expectancy at birth in East Germany and Poland, attributable largely to greater decreases from external causes. Among those over 40, absolute contributions to changing life expectancy were greater in the former GDR than in the other two entities in both sexes, largely attributable to circulatory diseases. A persisting East-west life expectancy gap in Germany of 2.1 years in men in 1997 was largely attributable to external causes, diseases of the digestive system and circulatory diseases. Higher death rates from circulatory diseases among the elderly largely explain the female life expectancy gap of approximately one year. CONCLUSIONS: This study provides further insights into the health effects of political transition. Post-transition improvements in life expectancy and mortality have been much steeper in East Germany compared with Poland. Changes in dietary pattern and, in Germany, medical care may have been important factors in shaping post-transition mortality trends.     

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.     

Disparit?ten der Krankenhaus-Fatalit?t nach proximalen Femurfrakturen in der DDR 1989

Zusammenfassung Der aufbereitete und pseudonymisierte Datensatz der Krankenhausabgangsdiagnose-Statistik der DDR wurde hinsichtlich der krankenhausbezogenen Fall-Fatalität für geschlossene proximale Femurfrakturen (ICD-9 820.0, 820.2, 820.8) untersucht. Die Fall-Fatalität von 20,2% nach durchschnittlich 60 Tagen ist im internationalen Vergleich und im Vergleich mit vorhandenen Daten für die alten Bundesländer hoch. Neben dem erwarteten Einfluss des Lebensalters war eine verminderte Sterblichkeit bei transzervikalen (intrakapsulären) Frakturen, bei Frauen und bei Sitz der behandelnden Klinik in Ost-Berlin zu beobachten. Diese nach Alter, Geschlecht, und Frakturtyp adjustierte Reduktion der Sterblichkeit in Ost-Berlin gegenüber den anderen Bezirken der DDR auf ein Drittel erklärt sich am wahrscheinlichsten durch eine bessere medizinische Versorgung in Ost-Berlin als Hauptstadt der DDR. Die bei dieser Modellanalyse beobachteten Disparitäten geben auch einen generellen Hinweis auf den Einfluss des medizinischen Versorgungsniveaus auf die mit dieser bevölkerungsmedizinisch bedeutsamen Erkrankung verbundene Sterblichkeit.

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Summary The revised and pseudonymized data set of the hospital discharge diagnoses of East Germany (German Democratic Republic, GDR) for 1989 was analyzed regarding the in-hospital case fatality of closed hip fractures (ICD-9 820.0, 820.2, 820.8). The case fatality of 20,2% during an average hospital stay of 60 days including between-ward and between-hospital transfers is high when compared to international data and data for West Germany. Apart from the expected influence of age, fatality was reduced for cervical (intracapsular) fractures, female sex, and for a location of the treating hospital within East Berlin. This reduction of the case fatality within East Berlin by nearly two thirds after adjustment for age, sex, and type of fracture compared to other regions is most likely explained by better medical treatment facitilities within East Berlin, the former capital of the GDR. The regional disparties that were observed during our model analysis give a hint towards the influence that medical care can have on the fatality associated with this on a population level relevant disease.

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Résumé Les dates revisés et pseudonymisés de la statistique hôpitalière des decharges de l'Allemagne de l'Est était analysee en respect de la fatalité en hôpital pour les fractures fermées du femur proximal (ICD-9 820.0, 820.2, 820.8). La fatalité de 20,2% apres en moitié 60 jours est haut en comparison international et avec les dates existents pour l'Allemagne de Ouest. En outre de l'influence expectée de l'âge une réduction de la fatalité pour les fractures cervicales, les femmes, et les hopitals localisés en Berlin de l'Est était observée. Cette réduction de fatalité adjustée selon l'âge, le sex, et le type de fracture en Berlin a un tiers comparée avec les autres regions de l'Allemagne de l'Est est plus probablement une consequence des services medicales superieurs en Berlin, la capitale de l'Allemagne de l'Est. Les disparités observées pendant cette analyse de modele donne une estimation général de l'influence des services medicales a la fatalité de cette maladie avec relevance pour la population.

     

Lebenserwartung, vorzeitig verlorene Lebensjahre und vermeidbare Sterblichkeit im Ost-West-Vergleich

The dynamics of convergence between East and West Germany in the life-prolonging process continued undiminished from 1990 until 2001. The regional differences in premature and avoidable mortality were clearly reduced, both between East and West and between the individual federal states. In the East and in the West there was an increase in life expectancy in all age groups and for both sexes, whereby the increase in life expectancy was considerably greater in East Germany and in all of the East German federal states. Also, the standardized potential years of life lost before the age of 65 decreased more intensively in East Germany. The women in East Germany achieved a lower premature mortality due to illness in the year 2001 than those in West Germany. In the initial year of 1990, the years of life lost were 27.2% greater. Unnatural premature mortality (especially due to accidents) was also relatively high in East Germany in the year 2001, but it is clearly being reduced. The avoidable mortality has been more than cut in half in all East German federal states since 1990. An almost complete alignment between East and West in regard to avoidable mortality was achieved in the year 2001. The phase of economic stagnation that can be observed in East Germany since 1997 has up to now not led to a worsening in the constitutive health references presented above.     

Das Sozio-oekonomische Panel (SOEP)

The Socioeconomic panel (SOEP) is currently the largest and longest running multidisciplinary longitudinal study in Germany. The first survey wave was completed in West Germany in 1984 and the study was expanded to include East Germany in June 1990. Every year since 1984 in West Germany and since 1990 in East Germany as well, a survey institute commissioned by the SOEP study has conducted personal oral interviews with more than 20,000 people in over 10,000 households. Although the SOEP does not contain any diagnostic information aside from grip strength for the evaluation of health status, instead using self-reported or proxy-reported indicators, it offers a dataset that is almost unparalleled in its ability to address a diverse range of topics with both objective and subjective indicators. Given the study's prospective longitudinal design, it is also outstandingly suited to controlling and correcting problems of selection that commonly arise in special samples (such as the Berlin Aging Study II). Covering a period of over 25 years, the SOEP also offers a number of possibilities for the analysis of the "natural experiments" that arise through changes in legislation. The SOEP's representative subsamples provide the basis for generalized conclusions about the total population living in private households and its migration samples also make an independent contribution for this population group. The numerous SOEP-based studies being published in the field of health sciences, most of which are currently concentrated around topics of health inequality and health economics, demonstrate the importance of this freely available research database for secondary analysis. Recent improvements in the survey concept will allow the SOEP to be used to an increased degree for analyses in the fields of public health and epidemiology.     

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.     

Berliners' models of heart disease causation

Following the collapse of socialism and subsequent German reunification, cardiac mortality rose unexpectedly in the former East Germany; although rates improved by mid-decade, a West/East health gradient persisted. Psychosocial stress from regime change, postsocialism, was one hypothesis proposed to explain the health transition. Absent from the scholarly conversation were individuals' own assessments of their illness experiences in this time of social upheaval. I hypothesized that such data might illuminate processes linking illness and social change. I analyzed illness narratives of East and West Berliners with heart disease, attending to subjective notions of causation. Both groups cited nonmodifiable and modifiable risk factors; half of the East Berliners incorporated additional material that referenced processes associated with postsocialism. I propose that ethnographic investigations of illness experiences can contribute to the development of more culturally relevant, comprehensive hypotheses of nonbiologic risk factors for cardiovascular disease.     

Pertussis in Germany: regional differences in management and vaccination status of hospitalized cases

The incidence of pertussis requiring hospitalization in children younger than 16 years was estimated by the use of an active surveillance-system. Of special interest were differences between West and East Germany following different vaccination strategies before reunification. In 1997 and 1998, 754 pertussis cases required a total of 11,151 hospital inpatient days. The incidence of hospitalized pertussis was 2.68/100,000 person years and this was significantly higher in East than in West Germany. In East Germany an unusually high percentage of hospitalized cases was found in children aged 6-15 years (45% versus 13% in West Germany). The difference between the regions may be due either to a different perception of the disease or to an increased immunity induced by prior disease or vaccination. In East Germany, pertussis was rare until reunification but it has increased significantly since then. Older children may thus represent a population at risk of pertussis having not had previous exposure to pertussis antigens.