Content

• General information
• On specific disease categories
• On data quality
• On attributes

General information

Notification paths according to the “Act on the Prevention and Control of Infectious Diseases in Man” (Infektionsschutzgesetz – IfSG) Source: RKI

• Notification: In Germany, the “Act on the Prevention and Control of Infectious Diseases in Man” (Infektionsschutzgesetz – IfSG) specifies infectious diseases and positive diagnoses of pathogens that are notifiable under federal legislation. The act also explicates two separate notification paths:
  1. Diseases and pathogens notifiable according to sections 6.1.1 and 7.1 of the IfSG, respectively, are reported on a named patient basis to the local public health departments. The local authorities further investigate the cases and perform contact tracing as necessary. Epidemiologically connected cases thus may become part of the notification data. For cases that match the case definitions provided by the Robert Koch Institute (RKI), data are anonymised and subsequently transmitted via the corresponding state health department to the RKI.
  2. Pathogens notifiable according to section 7.3 are notified to the RKI directly, where they are evaluated according to specific case criteria.
     Data collected under (1) and (2) are analysed and periodically published by the RKI Department for Infectious Disease Epidemiology.
  3. Several diseases and pathogens are notifiable under state specific regulations (of Bavaria, Berlin, Brandenburg, Hesse, Mecklenburg-W, Rhineland-Palatinate, Saarland, Saxony, Saxony-Anhalt and Thuringia) only. The case definitions for some but not all of the respective diseases were published in the Epidemiological Bulletin 5/2009. In SurvStat@RKI2.0, data concerning these regionally notifiable diseases and pathogens can be retrieved by selecting notification “via local and state health department” and setting the filter for the attribute notifcation regulation to <according to state specific regulations>.
• Data is updated weekly (diseases/pathogens reported via local and state health departments) or monthly (diseases/pathogens notified directly to RKI) in sync with the reference date for publication in the Epidemiological Bulletin. The data status differs for the two notification paths and is displayed separately, with the respective reporting period added in parentheses.
• Detailed information on the causative pathogen can be retrieved for most diseases. For diseases with an excessive number of specifiable pathogen subtypes or subspecies, these are subsumed to wider subcategories.
• Place: Cases notified via local and state health departments are allocated by county of the local health department which files the case (usually at the place of residence of the case person). Cases notified directly to RKI are allocated by the first three digits of the five digit postal code of the place of residence.
  The local attribution of the notified cases can be filtered and displayed at three levels either by Federal state or Territorial unit (NUTS Level 2) or County. For cases notified directly to RKI the lowest level – so-called Region – subdivides each territorial unit into its larger cities and a rural part.
  For the interpretation of the data it should be considered that the localization of cases only reveals the place of residence of the case persons. Information about the place of infection is not available in SurvStat@RKI 2.0.
• For regional comparisons of disease frequency (by state, territorial unit or county/region) it is recommended to use incidence (cases per 100,000 inhabitants per time period) rather than case numbers, to account for differences in population. This also applies for comparisons between age groups and/or sex. Because an increase of only 1 or 2 cases can lead to big differences in incidence among low population groups, it is advisable to view both absolute case numbers and incidence.
  FYI: Incidences <0.01 are rounded to 0.00.
• In contrast to earlier versions of SurvStat, which calculated the incidence for a time period of several years as an average p.a., the total incidence now refers to the entire time period selected in the ‘Filter Settings’ section (if no time period is specified: for the entire reporting period since 2001). In SurvStat@RKI 2.0, the mean incidence p.a. can be obtained by dividing the total incidence by the relevant number of years selected in the query.
• The population data necessary for the incidence calculation is provided by the states’ statistical offices and updated regularly. To calculate the incidence for a time period covering several calendar years, SurvStat@RKI 2.0 computes an average population from the population data of the relevant years.
• In SurvStat@RKI 2.0 new time variables have been implemented. The attributes season week and season year both come in two variations, named (27) and (40). The season year (27) starts with the 27^th calendar week and ends with the 26^th week of the following calendar year. Thus, the first season week (27) is the 27^th week of the calendar year. To display the seasonality of diseases having their lowest case numbers in the middle of the calendar year (e.g. norovirus gastroenteritis), season week (27) should be used as the attribute to display in columns of the results table. As the variable shifts the time-axis by 26 weeks, the resulting diagram will display the seasonality of the disease with an uninterrupted rise, maximum and fall of case numbers. For diseases with the highest case numbers in the first quarter of the year (e.g. influenza), season week (40) is recommended for a favourable display. To narrow the viewed data to a time span that does not cover the entire year, for example to selectively evaluate the influenza on-season period (calendar week 40 to week 20 of the following year), the off-season weeks can be deselected in the ‘Filter Settings’ section of the query form.
• Reference definition: Unless stated otherwise, all diagrams and tables in RKI publications refer to cases that comply with a reference definition. If you intend to compare the outcome of a query with an official RKI publication, the value of the attribute ‘reference definition’, which is preset to <Yes>, may not be deleted. For queries on diseases notifiable according to IfSG section 7.3 (those that are reported directly to RKI), the reference definition variable is not available, as have cases to fulfill are assessed at RKI using case specific criteria before.
• For a continuous representation of the time or age axis, the display option zero values should be selected, which causes all rows and columns of the results table to be displayed even if their fields show zero cases.
• Queries should be created step by step (filter settings > attributes to display > display options). For your convenience and documentation each query download comes with a summary of the utilised query settings.
• Tables, maps and diagrams should be completely labelled (including selected disease/pathogen, time, place and person, data status) to assure reproducible results.

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On specific disease categories

• Only direct detection of adenovirus in smears from conjunctiva is notifiable.
• Since March 2014 no update on echinococcosis cases is available.
• The number of reported VTEC depends on health care utilization and availability of diagnostic methods. Isolation of VTEC or identification of serogroups is not done routinely, albeit being necessary for an epidemiological analysis. For example, only for one third of the cases occurring during the VTEC O104 outbreak 2011 in Germany information on serotype is available. Therefore no valid interpretation of distribution of VTEC serotypes is possible.
• Only direct detection of Haemophilus influenzae in liquor (cerebrospinal fluid) or blood is notifiable.
• Since 2003 transmission and analysis of HUS cases is separated from VTEC cases, because in rare cases enteropathic HUS can also be caused by other pathogens than VTEC.
• Detection of Hepatitis C virus is notifiable, if there is no information on chronic infection.
• Only direct detection of influenza virus is notifiable. Since 21^st March 2007 any suspected, symptomatic or dead case of avian influenza is notifiable by physicians.
• Nationwide notification for pertussis, mumps, rubella and varicella infections was introduced on 29^th March 2013. Until then the diseases were only notifiable in the following federal states: Brandenburg, Mecklenburg-Vorpommern, Saxony, Saxony-Anhalt and Thuringia. With the nationwide introduction of the notification the case definitions were revised. Subsequently, the software used for filing and transmission of the cases had to be updated. Because of significant delay in the customization of their software, some local health departments were not able to report (complete) data on the above diseases for a prolonged period of time, which should be considered when interpreting these data.
• On 29^th March 2013 the notification regulations for congenital rubella infections were changed from a direct notification to RKI to a notification to the local public health departments. Furthermore, new case definitions were implemented. As data from the two notification paths must be analysed separately, the data on congenital rubella since 2001 cannot be displayed in a single table/diagram.
• Only direct detection of Listeria monocytogenes in blood, liquor (cerebrospinal fluid) and other normally sterile material or smears from neonatals. Since 1^st January 2004 the mother of a neonatal with laboratory confirmed Listeria monocytogenes will be included as an epidemiological confirmed case, even if there is no laboratory confirmation for the mother herself. Data in this category before and after 2004 is not comparable.
• Since March 2014 no update on malaria cases is available.
• Direct detection of Methicillin-resistant staphylococcus aureus (MRSA) in blood or liquor (cerebrospinal fluid) is notifiable since 1^st July 2009. According to the reference definition all laboratory confirmed cases are counted irrespective the clinical symptoms of the cases.
• Only direct detection of Neisseria meningitidis in liquor (cerebrospinal fluid), blood, hemorrhagic skin lesions or other normally sterile material is notifiable.
• Only direct detection of norovirus in stool specimens is notifiable. Since 2011, only cases that meet both clinical and laboratory criteria fulfill the reference definition. Therefore no information on epidemiological confirmed cases is available. An underestimation of case numbers can be assumed. This also influences the description of trends in time, geographical distribution and age distribution of cases, because the proportion of not laboratory confirmed cases can vary between federal states and also depends on the different outbreak settings.
• Infections with Salmonella Paratyphi B (formerly S. Java) are included in the disease category salmonellosis (see "SAL / S. Paratyphi B (enteric pathovar, tartrate positive, SopE negative, avrA positive) - formerly S. Java"). Infections with the systemic pathovar of S. Paratyphi B as well as S. Paratyphi A and C (causing paratyphus), see under disease category paratyphus.
• Only direct detection of Salmonella Typhi and Paratyphi is notifiable.
• The monophasic subtype of S. Typhimurium (see "SAL / S. Typhimurium, monophasic") was included in the software only in May 2012 (SurvNet@RKI; Version 0.8.12) and not available at every local public health department. Time series analysis for this subtype is not possible.
• Since March 2014 no update on connatal toxoplasmosis cases is available.
• Only falling ill with or dying from tuberculosis requiring treatment as well as direct detection of the pathogen and the detection of acid fast bacilli in stained sputum smears are notifiable.

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On data quality

• Electronic transmission. RKI developed a software (SurvNet@RKI) that can be used free of charge by local public health departments and state health departments for recording cases, analysis and transmission of notification data. Local public health departments can also decide to use other commercial software products which are available on the market. The use of different software products on local level could lead to compatibility problems and can influence data quality, e.g. losses of data, double entries and incorrectly transmitted informations.
• Completeness of reporting. Cases of infectious disease can only be captured in the notification system if they access the health care system and are notified by physicians, hospitals or laboratories. If an infected person, because of asymptomatic or mild disease, does not consult a physician, the physician does not initiate further laboratory diagnostics or after a diagnosis no notification is made, the case could not be captured in the notification system. Depending on disease and notification regulations this underestimation and underreporting can vary. The case numbers as presented in SurvStat@RKI should not be interpreted as true disease incidence, but as incidence of notified cases.
• Data completeness. With every notified case important epidemiologcial informations are collected, e.g. age, sex, clinical symptoms, laboratory methods. This information is not every time complete on the notification forms and must be investigated by the local public health departments. If this information can’t be investigated and is not transmitted to RKI and therefore not available in the respective analysis.
• Timeliness. Cases are assigned to a week of notification depending on the date when the local public health department is notified of the case. In 2013 the median time period between onset of symptoms and notification date was 5 days. For notifications directly to RKI the month of diagnosis is used as date for statistics.

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On attributes

Notifiable diseases (and diagnoses of pathogens) listed by notification regulation. The first column shows the RKI specific disease code which is used as a prefix for the pathogen listing (e.g. SAL / S. Brandenburg).

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Federal States (Abreviation in brackets) and related Territorial Units (NUTS level2)

• Baden-Württemberg (BW)
• Stuttgart
• Karlsruhe
• Freiburg
• Tübingen
• Bavaria (BY)
• Oberbayern
• Niederbayern
• Oberpfalz
• Oberfranken
• Mittelfranken
• Unterfranken
• Schwaben
• Berlin (BE)
• Berlin
• Brandenburg (BB)
• Brandenburg
• Bremen (HB)
• Bremen
• Hamburg (HH)
• Hamburg
• Hesse (HE)
• Darmstadt
• Giessen
• Kassel
• Mecklenburg-Vorpommern (MV)
• Mecklenburg-Vorpommern
• Lower Saxony (NI)
• Braunschweig
• Hannover
• Lüneburg
• Weser-Ems
• North Rhine-Westphalia (NW)
• Düsseldorf
• Köln
• Münster
• Detmold
• Arnsberg
• Rhineland-Palatinate (RP)
• Koblenz
• Trier
• Rheinhessen-Pfalz
• Saarland (SL)
• Saarland
• Saxony (SN)
• Dresden
• Chemnitz
• Leipzig
• Saxony-Anhalt (ST)
• Saxony-Anhalt
• Schleswig-Holstein (SH)
• Schleswig-Holstein
• Thuringia (TH)
• Thuringia

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