News Journal of Open Public Health Data launched 25

A marked increase in the number of multidrug-resistant (MDR) tuberculosis (TB) cases entirely related to patients born in the Former Soviet Union was observed in France in the last two years. Very few cases were clustered, suggesting it is a consequence of recent immigration of patients already infected in their country of origin. This major increase challenges the existing structures for management of MDR and extensively drug-resistant TB (XDR-TB).

A marked increase in the number of multidrug-resistant (MDR) tuberculosis (TB) cases entirely related to patients born in the Former Soviet Union was observed in France in the last two years.Very few cases were clustered, suggesting it is a consequence of recent immigration of patients already infected in their country of origin.This major increase challenges the existing structures for management of MDR and extensively drug-resistant TB (XDR-TB).
We report herein a drastic surge in the number of multidrug-resistant tuberculosis (MDR-TB) cases diagnosed in France in the last two years.MDR-TB, defined as TB with Mycobacterium tuberculosis strains resistant to isoniazid (INH) and rifampicin (RMP), is a threat to public health in some parts of the world, notably in Eastern Europe and Central Asia [1][2][3][4].In these regions, and particularly in Former Soviet Union (FSU) countries, nearly one third of new cases and two thirds of previously treated cases are MDR-TB cases [2,5].In France, which is a low TB incidence country [6], MDR-TB represented 0.7% of new cases and 6.9% of previously treated cases up to 2004 [7].

Surveillance of resistant tuberculosis
All MDR-TB strains sent to the French National Reference Center for Mycobacteria (NRC-MyRMA) between 2006 and 2012 for MDR confirmation and second-line drug susceptibility testing against ofloxacin (OFX), amikacin (AMK), kanamycin (KAN), and capreomycin (CAP) were included.Susceptibility tests were performed on Lowenstein-Jensen medium following the proportion method [8], by using the critical proportion of 1% and the following concentrations: RMP 40 mg/L, INH 0.2 and 1 mg/L, OFX 2 mg/L, AMK and CAP 40 mg/L, KAN 30 mg/L.Detection of mutations involved in the resistance to the above antibiotics was performed by using the line probe assays MTBDRplus and MTBDRsl (HAIN Lifescience) and by gyrA and gyrB sequencing.
Extensively drug-resistant TB (XDR-TB) was defined as MDR-TB with additional resistance to any of the fluoroquinolones and to at least one of the three injectable drugs, KAN, AMK or CAP, and pre-XDR-TB was defined as MDR-TB with additional resistance to either fluoroquinolones or one of the three injectable drugs.Genotyping was performed using the 24-loci mycobacterial interspersed repetitive-unit variable-number tandem repeat (MIRU-VNTR) method.A cluster was defined as two or more patients whose strains had identical genotype pattern.

Results
The NRC-MyRMA received 409 MDR strains from distinct patients between 2006 and 2012.The annual number of MDR-TB strains remained stable around 50 between 2006 and 2010, but increased to 69 in 2011 and 92 in 2012.The surge was related to an increase in patients born in the FSU, from an annual average of nine in 2006 to 2010 to 21 in 2011, and 47 in 2012 (Figure 1).Furthermore, the annual number of XDR-TB cases increased from two in 2006 to 2008 (5% of MDR-TB) to four in 2009 (7% of MDR-TB), six in 2010 (13% of MDR-TB), seven in 2011 (10% of MDR-TB) and suddenly 17 in 2012 (18% of MDR-TB) (Figure 3).
Almost three quarters of the 40 XDR-TB strains (n=31) were isolated from patients born in FSU, the remaining being born in other European countries (n=4) and in Africa (n=5).All 17 XDR strains identified in 2012 were from patients born in FSU, including 14 born in Georgia.Among all 113 MDR strains identified in FSUborn patients during the seven-year period, 31 (27%) were XDR, compared to nine of 296 (3%; p<0.001) among strains isolated from patients born in other countries.Among the 92 MDR strains in 2012, the proportion of XDR and pre-XDR strains was higher for patients born in Georgia (89%) than for other FSU countries (52%; p<0.01), and for non-FSU countries (9%; p<0.001) (Table ).
The date of arrival in France was known for 29 of the 47 FSU-born MDR-TB patients identified in 2012: 27 arrived within one year before hospitalisation, including 10 that arrived within one month.The two remaining patients were in France for two and 10 years, respectively.
The MIRU-VNTR patterns of the 47 strains isolated in 2012 from FSU-born patients revealed that 32 (68%) belonged to the Beijing lineage, 10 (21%) to the LAM lineage, one to the Haarlem and one to the Ural lineages.Three isolates had MIRU-VNTR patterns referred as non-typable.Three clusters of five, nine and 10 strains were identified among the 32 Beijing strains, and three clusters of two, two and three strains among the 10 LAM strains.The combination of phenotypic and genotypic antibiotic patterns with MIRU-VNTR patterns decreased the clustering to only one pair in the Beijing lineage and one pair in the LAM lineage, each related to individuals within one household.All other strains had distinct genotypic and phenotypic susceptibility profiles ruling out transmission.Of note, only six (two patients born in China, one in Mongolia, one in France and two in Africa) of the MDR strains from non-FSU patients belonged to the Beijing lineage.

Discussion
In France, the sudden increase in the number of MDR-TB strains isolated since 2011 was almost entirely related to the surge of MDR strains from FSU-born patients, who accounted for more than 50% of MDR-TB cases in 2012.Specifically, the increase was related to patients born in Ukraine, the Russian Federation and above all in Georgia.
In these three countries, TB incidence was estimated to be between 90 and 125 per 100,000 population in 2011 and the percentages of MDR-TB cases are estimated to be 10-20% in new TB cases and ca.45% in retreatment cases [9][10][11][12].Africa cannot be deduced from rates observed in their countries of origin [13].
Previous TB treatment history is known to be a risk factor for resistance [14][15][16], and this is confirmed in France where two thirds of the FSU-born MDR-TB patients have been previously treated.In addition, more than one third of the FSU-born MDR-TB patients from 2012 had in fact XDR-TB, and all of the XDR-TB patients were FSU-born.Consequently, the important surge in MDR-TB observed recently in France is compounded by a problematic management of antibiotic treatment regimens before the availability of comprehensive susceptibility tests results, reinforcing the importance of universal use of genotypic susceptibility tests in this population.While it is possible that an increase in immigration from the FSU overall could in part explain the observed increase in cases, it is worth mentioning that nine in 10 FSU-born MDR-TB patients are recent immigrants and that one in three arrived only a few days before hospitalisation.Therefore, the possibility needs to be considered that immigration to France may be driven by health reasons and clinicians should be aware of it when such patients arrive in the healthcare system.
In the present study, the genotyping analysis revealed four lineages (Beijing, LAM, Haarlem and Ural) already reported in the FSU [17][18][19], although the Beijing family was more frequent (68%) in our study.Of interest, the combination of MIRU-VNTR and antibiotic resistance genotypes and phenotypes suggested that almost all strains defined as clustered by MIRU-VNTR were in fact distinct.Thus, the recent increase in France in the number of FSU-born MDR-TB patients is more likely to be a result of recent immigration of patients infected in their country of birth where multiple MDR strains are circulating, than from cross-transmission in France among a closed group.
In conclusion, this increase challenges the existing structures for management of MDR and XDR-TB especially in a low-endemic country for TB.
The members of the MDR-TB Management group of the NRC were:  In this communication, we report the increased incidence of severe Streptococcus pyogenes (group A streptococcus; GAS) infection in Ireland and a predominance of emm1 in 2012.In the first six months of 2013, we observed a further increase in iGAS and the emergence of emm3.

Background
S. pyogenes is a major human pathogen that causes a wide spectrum of clinical manifestations.These range from common superficial skin infections and pharyngitis to invasive infections such as bacteraemia, meningitis, cellulitis, pneumonia, and the more severe necrotising fasciitis (NF) and streptococcal toxic shock syndrome (STSS).Invasive GAS (iGAS) infections, though relatively uncommon compared to highly prevalent non-invasive GAS infections, remains a significant global cause of morbidity and mortality.Seven-day case fatality rates range from 8% to16%, with high rates approaching 50% often associated with STSS [1].
The M protein, encoded by the emm gene, is the major virulence factor and an important epidemiological typing tool.In excess of 200 emm types have been documented to date [2].Whereas all types may be associated with invasive GAS (iGAS), emm1 and emm3 have been particularly associated with severe iGAS infections and the resurgence of these infections that has occurred since the 1980s [3].The incidence of iGAS disease exhibits seasonal patterns in addition to periodic upsurges [4].Moreover, the prevalence of emm types has been shown to exhibit temporal and geographical variations [5,6] [10].Since 2005, enhanced surveillance, which includes collection of information on isolate site, clinical presentation, risk factors and patient outcome, has been conducted for iGAS cases on a voluntary basis [11].In 2012 a laboratory reference service commenced to which isolates are voluntarily submitted for emm sequence typing.

Clinical data collection
Demographic information on iGAS cases was analysed using data which had been entered in the national electronic infectious disease reporting system (Computerised Infectious Diseases Reporting System, CIDR).CIDR allows exchange of information between laboratories, regional departments of public health and the Health Protection Surveillance Centre (HPSC) and is used to notify iGAS and record enhanced surveillance findings.

Epidemiological typing
From early 2012 onwards, all available iGAS isolates (n=109 in 2012; n=67 in January to June 2013) were submitted by clinical microbiology laboratories to the GAS reference laboratory for emm sequence typing.
Isolates which had been archived in 2011 (n=28) were sent to be typed retrospectively.Typing was performed by sequencing the hypervariable region of the emm gene as previously described [12].

Statistics
Incidence rates were calculated using the 2011 population census data.Incidence rate ratios were calculated along with their 95% confidence intervals (CI; Fisher's exact test).The year 2005 was excluded from the analysis of enhanced surveillance data as there may not have been complete data reporting for that year.Difference in the emm type distribution was calculated using Fisher's exact test.

Epidemiology
In 2012, 117 confirmed cases and five probable cases of iGAS infection were notified.This corresponds to an annual incidence of 2.66 cases per 100,000 (95% CI: 2.21-3.17per 100,000).This is the highest annual incidence since iGAS became notifiable in 2004.Annual incidences for 2004 to 2011 have ranged from 0.8 per 100,000 in 2004 to 1.65 per 100,000 in 2008, with incidence rates levelling out in 2009 to 2011 (range: 1.31-1.48cases per 100,000) [11].In 2012, the highest number of cases occurred in the months May through July, with the lowest in September (Figure 1).A further increase occurred during the first six months of 2013 with a total of 102 cases notified from January to June compared to 78 and 44 cases in the first six months of 2012 and 2011, respectively (Figure 1).

Typing results
A total of 109 isolates (89%) collected from reported iGAS cases in 2012 were typed by emm sequence typing (Figure 3).The most prominent types were emm1, which accounted for 48.6% of isolates, followed by emm12 (9.2%) and emm28 (7.3%).Whereas, emm1 was equally distributed between males and females, emm12 and emm28 were more predominant in males (65%) and females (87.5%), respectively, although neither value was significant (p=0.34 and 0.065, respectively).The emm1 type accounted for 17 of 25 STSS cases that were typed and for seven of eight deaths.Only two isolates of emm1 were detected from October to December 2012, when no cases of STSS were reported (Figure 3).Sixty-seven isolates (66%) have so far been typed from all iGAS cases reported in January to June 2013.The number of emm1 isolates has declined somewhat, accounting for 40% of typed isolates compared to 54% of typed isolates for the same period in 2012 (January-June).However, there has been a notable increase in emm3 in the first half of 2013 with 22% (n=15) of typed isolates belonging to this emm type contrasting with 1.5% (n=1) for the same period in 2012 (p=0.0001) and 4% (n=4) in total for 2012.There is limited information regarding the type distribution of iGAS in Ireland prior to 2012.However, 28 iGAS isolates (42% of total) from 2011 were retrospectively typed and showed a lower prevalence of emm1 (25%; eight of 28) and a higher prevalence of emm12 (32%; nine of 28) compared to 2012 and 2013.

Discussion
A marked increase in notifications of iGAS occurred in Ireland in 2012 with a further increase observed in 2013.
Increased incidences of iGAS have also been reported in 2012/13 in Finland, Norway, Sweden, and England, suggesting an increase in iGAS infections in Northern Europe [13,14].Public Health England reported 1,038 iGAS cases for weeks 37/2012 to 16/2013 compared to 691 for 2011/12 and 907 for 2008/09, the last peak season for iGAS infection [14], indicating that the upsurge in Ireland (April-July 2012) pre-dated that in neighbouring England.iGAS has been notifiable in Ireland since 2004.It is therefore unlikely that the initiation of iGAS typing in 2012 and alerts issued on iGAS in July 2012 and April 2013 would have had a significant effect on the overall notification rate.There is evidence to suggest that viral infections such as influenza can contribute to an increased risk of invasive bacterial infections such as iGAS [8,9].The short and mild 2011/12 influenza season in Ireland is unlikely to have had an impact on the increased incidence of iGAS in 2012.However, in 2013, the influenza season was more prolonged and may have been a contributing factor to increased rates of iGAS [15].
The high prevalence of emm1 is likely to have played a significant role in the increased incidence of iGAS in 2012.The lower prevalence of emm1 and higher prevalence of emm12 in 2011 compared to the incidence of these types in 2012 suggests a possible change in the epidemiology of GAS between 2011 and 2012.However, no major conclusions can be drawn due to the small number of isolates which were typed in 2011.Significantly, England, Norway and Sweden have also reported a high prevalence of emm1 in 2012/13 [13,14].
The increased incidence of emm3 in 2013 is of concern given its association with a higher case fatality rate compared to other emm types [16].Significantly, in 2013, emm3 accounted for five of eight fatal cases in Ireland for which typing data was available.An increased prevalence (11%) of emm3 was also reported in Sweden in 2012 [13].Continued typing of isolates will be required to confirm this trend in 2013 and to monitor any further changes in epidemiology.
The incidence of iGAS infections in Ireland, although increased in 2012, was lower than the 2012 upsurge rate reported in Sweden (6.1 per 100,000 population) [13].Moreover, the overall annual incidence rates (0.8-1.65 in 2004-11) in Ireland prior to the upsurge were lower than that reported in the United Kingdom (UK), the Nordic countries and North America, which have in general higher reported incidence rates in the range 2.5-5.0 per 100,000 [4,11,13].The reason(s) for the lower incidence rate of iGAS in Ireland is unclear [11].A relatively high empiric antibiotic consumption has previously been suggested as a likely explanation [11].For example, in 2010, outpatient penicillin use was higher in Ireland at 10.70 defined daily doses (DDD) per 1,000 inhabitants per day than in Finland at 6.6 DDD, Sweden at 7.1 DDD and the UK at 8.6 DDD per 1,000 inhabitants per day [17].A small number of cases may also have gone unreported due to differences in case definitions between Ireland and other countries as previously reviewed [11].Temporal and geographical fluctuations in iGAS infections may also be due in part to emm type distribution, population susceptibility, prevalence of certain risk factors, and environmental factors such as climate and population density [4,11,18].
Similar to other European countries, seasonal variation in iGAS infections was observed in Ireland, with lowest incidence rates in late summer/autumn as reported elsewhere [4,13,19].The peak rate of iGAS infections in Ireland in May 2012 and 2013 occurred later than in Sweden and other Nordic countries which generally exhibit peak incidences in the first quarter of each year [13,19].However, occasional peaks in summer can also occur in these countries [13,19].Noteworthy is the rising incidence of iGAS infections reported in April 2013 in England, possibly indicating a late upsurge similar to that observed in Ireland [14].Seasonal variations in iGAS may reflect climatic differences such as daylight/ sunlight hours, rainfall/humidity, temperatures and seasonal behavioural patterns [4,19] We report here on the emergence of STIs among very young adolescents in Catalonia and draw attention to the potential risk of a gonorrhoea outbreak and transmission of other STIs.We present a preliminary descriptive analysis of epidemiological and microbiological characteristics of cases from 1 January 2012 to 30 June 2013.We also compare the number of cases reported during first six months of 2012 and of 2013.

Surveillance of sexually transmitted infections in Catalonia
Three institutional information systems are used for STI surveillance in Catalonia: a name-based mandatory disease notification registry (MDI), STI sentinel surveillance registry (RITS) and microbiological notification system (SNMC), as described elsewhere [ Gonorrhoea was the second most frequently reported STI during the study period: nine cases were reported in the first half of 2013 whereas in the same period of 2012, there was only one (Table 2).

Other sexually transmitted infections
From January 2012 to June 2013, a total of 17 cases of other STIs were reported among adolescents aged 14-15 years.All except one were girls; one 15 year-old homosexual boy with syphilis was reported.Unlike the situation for the gonorrhoea cases, only four of the 17 cases with other STIs were born outside of Spain.
Chlamydia trachomatis infection was the most common STI (11 of the 27 cases) and Gardnerella vaginalis infection ranked third (3/27).When comparing January to June of 2012 versus 2013, no increase was observed (Table 2).

History of sexually transmitted infections
Most of the cases did not know their HIV status, one had a previous STI in the past year and only three reported condom use at last sex.One case aged 14 years reported having three sexual partners during the last 12 months and two cases reported having a new sexual partner during last three months.Most of these very young adolescents (7/27) were diagnosed in a sexual and reproductive health service or by a family/general practitioner team (n=7).Four cases were diagnosed by paediatricians and two were diagnosed at the Sexually Transmitted Infection Unit.Contact tracing investigations, initiated by the healthcare provider who diagnosed the patient, were carried out for seven of the 15 cases for whom epidemiological information was available (initiation of contract tracing following diagnosis is obligatory in Catalonia).
No information on use of a newly introduced partner notification card was reported.Active contact tracing follow-up was carried out by the Barcelona city epidemiological surveillance unit for the cluster of three gonorrhoea cases.

Microbiological detection
The microbiological notification system detected C. trachomatis (n=8), Neisseria gonorrhoeae (n=3) and herpes simplex virus (n=1).Polymerase chain reaction (PCR) was used to detection of C. trachomatis and no further molecular serovar typing was performed.The three N. gonorrhoeae detections were confirmed by culture, all of which were sensitive to ceftriaxone.No molecular typing was carried out.

Background
Sexual activity in early adolescence contributes to an increased burden of unplanned pregnancy, abortion, transmission of STIs, including exposure to HIV and can have an impact on a young person's general health [5,6].
Spain has the lowest legal age of consent for sexual activity (13 years) in the European Union [7].According to the last National Sexual Health and Reproduction Survey, 34% of those interviewed declared starting sexual intercourse before 16 years of age -two-fold higher than in the previous survey (12% in 2003) [8,9].In contrast, the legal age for use of health services without parental consent is 16 years [10].
In Catalonia, epidemiological data from individualised mandatory STI reporting, introduced in 2007 [2], showed an increase between years 2007 and 2012 for gonorrhoea and syphilis and two outbreaks of lymphogranuloma venereum (LGV).Resistance of N. gonorrhoeae to ceftriaxone was documented in Catalonia in 2011 [1].

Discussion
The increase seen in the number of gonorrhoea cases and the occurrence of other STIs in these very young adolescents raises issues regarding the health and vulnerability of this population [11].In addition, the data indicate a special vulnerability of foreign-born minors diagnosed with gonorrhoea, as the proportion of those born outside Spain is higher than that seen for other STIs and in other age groups [1].Rapid public health responses are needed to address these issues in very young adolescents (Box).
The reporting of two gonorrhoea cases linked to a common third adolescent and exposure through a social network points towards a potential risk for gonorrhoea to spread among a young population with access to new technologies.In addition, the occurrence of noncongenital syphilis in a homosexual boy (born outside Spain) highlights the potential transmission of this infection and potential for increased exposure to HIV due to unprotected sexual intercourse.In Catalonia, syphilis is mostly observed among men who have sex with men, with 37% HIV coinfection [1].Sex-related behaviour within the very young adolescents showed a low condom use at last sexual intercourse; one case had had more than two sexual partners in the last 12 months.During early puberty, most minors enter into a rapid increase in cognitive and emotional development and face a period influenced by peers and other adults [5,6].Further analysis of sexual behaviour and STI/HIV exposure should be carried out in this population.Health professionals, in particular paediatricians, should be aware of the recent cases and be prepared to test for these infections in their very young adolescent patients.There should also be adequate follow-up, which respects privacy and confidentiality issues and the cognitive maturity of these very young adolescents concerning their own sexual health.The three surveillance systems have been shown to be useful, allowing us to identify and describe the epidemiology of this vulnerable population.Nevertheless, the coverage and case-finding capacity of these systems needs to be improved.

Introduction
Mumps is a vaccine-preventable viral disease, typically characterised by swelling of the parotid glands, but can also cause severe complications like orchitis, meningitis, encephalitis or pancreatitis [1,2].The disease usually occurs among children and in the prevaccine era, the annual reported mumps incidences in Western European countries ranged between 100 and 600 per 100,000 inhabitants [3].With the availability of a live-attenuated mumps vaccine since the 1960s [4], disease incidence dramatically decreased in countries with mumps vaccination programmes [5,6].Over the past years, however, numerous reports from different countries with long-established vaccination programmes have been published about extensive mumps outbreaks that occurred predominantly among vaccinated children, adolescents, and young adults [7][8][9][10][11][12][13][14][15].
Until 2013, mumps has been notifiable in Germany only in the five Eastern federal states (EFS) of former East Germany.During the years 2001 to 2011, annually reported incidence for all EFS ranged between 0.26 and 0.78/100,000 [16].There was no mandatory notification system in place in the remaining 11 Western federal states (WFS) of former West Germany.However, if an outbreak occurs in an institutional setting, the 'German Infection Protection Act' requires the institution to immediately inform the district health authority.A recent comprehensive survey suggested an increase in the number of mumps outbreaks over the past 10 years [17].The largest recorded outbreak occurred in the WFS of Bavaria in 2010/11.Voluntary (ad-hoc) reporting was set up during the outbreak period and identified 295 cases.
Although mumps incidences have been available for EFS for the past 10 years, incidences cannot be extrapolated to the 11 WFS due to historical differences in vaccination schedules and coverage rates.While West Germany had recommended one dose of mumps vaccine as part of the routine childhood vaccination schedule from 1976 onwards, East Germany had no mumps vaccination programme in place until reunification in 1990.Since 1991, two doses (in the second and sixth year of life) have been recommended throughout the reunified Germany, since 2001 with the first dose given at 11-14 months and the second dose at 15-23 months of age [18]; the vaccine strain predominantly used is Jeryl Lynn.Although routine mumps vaccination was adopted in EFS 15 years later than in WFS, vaccination coverage rates at school entry have been substantially higher in EFS since introduction of coverage monitoring in 1998 (Figure 1) [19]. In

Definitions
For ASHIP data, a mumps case was defined as a person diagnosed with a mumps-related International Classification of Diseases (ICD-10) code (B26.0orchitis,B26.1-meningitis, B26.2-encephalitis, B26.3pancreatitis, B26.8-'other complication', B26.9-'no complication'), and for notification data as a person fulfilling the mumps case definition (clinical case, i.e. more than two days of one-or two-sided parotidal swelling without any other apparent cause, and/or clinical case with epidemiological link and/or clinical case with laboratory confirmation) [20].Incidence based on ASHIP data was defined as number of outpatient cases per 100,000 statutory health-insured [21], whereas incidence based on the mandatory notification system was defined as number of outpatient cases per 100,000 inhabitants in Germany [22].The German federal states of Brandenburg, Mecklenburg-Western Pomerania, Saxony, Saxony-Anhalt, and Thuringia were classified as EFS; Baden-Württemberg, Bavaria, Berlin (comprising of the former Eastern and Western part of the city), Bremen, Hamburg, Hesse, Lower Saxony, North Rhine-Westphalia, Rhineland-Palatinate, Saarland, Schleswig-Holstein as WFS.The Bavarian outbreak period ranged from the third quarter of 2010 to the second quarter of 2011, the non-outbreak period were the remaining quarters in the years 2007 to 2011.

ASHIP data structure and data included in the analysis
Statutory health insurance physicians send their reimbursement claims for provided ambulatory medical services, based on the ICD-10 code, to their corresponding regional ASHIP on a quarterly basis.

ASHIP data cleaning
We only included confirmed diagnoses that were labelled as 'current state' for the calculation of incidences.To limit the dataset to a single diagnosis per unique ID, we used the following algorithm: For data from Bavaria, Rhineland-Palatinate (2007-11) and regional parts of North Rhine-Westphalia (2008-11), step 3 had to be omitted as the transmitted data did not routinely contain information on 'type of diagnosis'.

Mandatory and ad-hoc notification data
We retrieved mandatory mumps notification data reported from EFS through the German electronic surveillance system 'SurvNet' [23] that is routinely used by public health authorities to anonymously report information on inpatient and outpatient cases with notifiable diseases to the national level.The 'SurvNet' system was also used by district health authorities for the voluntary ad-hoc mumps reporting during the outbreak in Bavaria 2010/11.Notification datasets contained information on age, sex, date of disease onset, notification week, district/state of residence, vaccination status, and whether the case required hospitalisation.

Statistical analysis
We used chi-square test to test differences in incidences and proportions and Poisson regression to determine trends in incidence rate ratios (IRR).P values were defined as statistically significant if <0.05.Statistical analysis was performed by using Stata version 12.1 (StataCorp, Texas, US).
Mean annual mumps incidence in 2007 to 2011 was significantly higher in WFS than in EFS (10.9/100,000 versus 7.5/100,000; p<0.005).Incidences ranged between 7.0 and 8.4/100,000 in EFS, with a significant declining trend over the five years under observation (IRR=0.95;95% CI: 0.93-0.97;p<0.005), and between 9.8 and 12.6/100,000 in WFS (IRR=0.96;95% CI: 0.95-0.96;p<0.005).Stratification by age group showed a significant decreasing trend for incidences in the under 20 year-olds in EFS.In the WFS, incidences significantly decreased in the age groups of under 20 year-olds and of those aged 40 years and older, but significantly increased in the 20 to 29 year-olds (Table ).The mean annual incidence of orchitis was higher in WFS than in EFS (0.72/100,000 versus 0.12/100,000 male cases; p<0.005).The proportion of orchitis complications among male cases by age group and geographic region is displayed in Figure 2.

Description of the 2010/11 outbreak in Bavaria based on ASHIP data
Between 2007 and 2011, Bavarian physicians billed 6,111 confirmed outpatient mumps cases to the   The proportion of claimed male cases was higher during the outbreak period than in the non-outbreak period (52.0%versus 47.5%; p<0.005), and a comparison of age-specific incidences indicated that the outbreak affected mainly the age group of 15-34 year-olds (Figure 3).Furthermore, the proportion of orchitis complications was significantly higher during the outbreak period compared to the non-outbreak period (17.7% versus 11.7%; p<0.005); all other proportions of complications showed no significant differences (data not shown).

EFS: Comparison of ASHIP data with mandatory notification data
In  [29].However, the 27 countries differ in their mumps surveillance systems, case definitions and time points of routine mumps vaccine introduction [30,31], and comparisons are therefore difficult.
Comparison of the mandatory notification data with ASHIP data in EFS indicated severe underreporting, especially among adults.Underreporting could even be higher, as we only included cases coded as confirmed and diagnosed in an ambulatory practice.Our findings suggest that in EFS, where mandatory mumps surveillance has been in place since 1964 [24], physicians diagnose mumps, but fail to report cases to public health authorities.This has important implications as Germany has introduced nationwide mandatory reporting of mumps as of March 2013.To retain reliable mumps notification data, it is crucial not only to (re)inform physicians about their reporting duty, but to think of new strategies to ease reporting.One approach could be to develop computer tools that directly link the ICD coding of notifiable infectious diseases with a report to the health authorities.
There is an increasing use of electronic health records or claims data to estimate disease trends or disease burden, especially for admission or discharge ICD codes from hospitals, e.g. for rotavirus, gonorrhoea, or varicella [32][33][34].In Germany, ICD-10 codes have previously been used to assess the herpes zoster disease burden also in the outpatient sector [35], and to assess reporting completeness of notifiable disease surveillance systems [36,37].However, electronic health records or claims data cannot and should not replace a surveillance system, as the data are usually only available with a time lag of several months, precluding rapid containment actions in the event of an outbreak, and are primarily intended for documentation or reimbursement, not surveillance purposes.In the case of ASHIP data, important information such as vaccination status at diagnosis or required hospitalisation is lacking.Nevertheless, such data can be an important source to assess the magnitude of incidences, disease trends and underreporting, and their reliability to determine communicable disease trends and burden should be further explored, also for the outpatient sector.
Using ASHIP data to estimate mumps incidences had several limitations related to data structure.There are no standardised guidelines for physicians of when to code a case as suspected or confirmed.Aiming at a conservative estimate, we decided to only include confirmed diagnoses.This restriction, as well as limiting the dataset to one observation per patient (who may have had several physician consultations during one disease episode), reduced the initial dataset considerably during the cleaning process.Therefore, the extent of the reduction cannot be interpreted as an indicator for the ASHIP data quality per se.As laboratory confirmation is not required to code a case as confirmed, the proportion of laboratory confirmations is unknown.Moreover, ASHIP data only cover ambulatory cases.However, since mumps has a very distinct clinical presentation and the vast majority of mumps patients remain outpatients or have consulted their ambulatory physician before complications may require hospitalisation, it can be assumed that our incidence estimates are a good reflection of the true disease incidence.
Our dataset did not include the ca.15% of the population with private health insurance.However, we used the ASHIP population as denominator to calculate incidences and do not expect that mumps vaccination coverage differs substantially between privately and statutory insured.Finally, as information on 'type of diagnosis' is routinely missing for Bavaria, Rhineland-Palatinate and parts of North Rhine-Westphalia, we could not exclude diagnoses coded as 'previous state', 'unknown' or 'not provided' in the data cleaning process.However, if proportions of reduction had been applied to these federal states as observed for the others (step 3: 26.9%; step 4: 13.6%), the total number of cases would have been reduced by only 899 (2.7%).

Conclusions
ASHIP data proved a valuable alternative data source to estimate mumps incidences.The identified shift in age distribution, the vaccination status of reported cases, and serosurveys indicate that inadequate coverage (with less than two mumps vaccine doses) is the main reason for outbreaks und sustained mumps virus circulation in Germany.In 2010, the German Standing Committee on Vaccination (STIKO) recommended an additional MMR vaccination for persons born after 1970 with less than two measles vaccinations in their childhood [18], a recommendation that may simultaneously close some of the existing mumps vaccination gaps in adults.However, no catch-up vaccination activities for mumps have been initiated so far.In view of recent mumps outbreaks among adolescents and young adults and indications of waning immunity, the option of a third routine mumps vaccine dose is being discussed in the scientific literature [10,14,38].However, comprehensive data on the long-term effectiveness of two-dose mumps vaccination (e.g.measured during outbreaks among adolescents and young adults) and on the additional benefits of a third dose are lacking.
For the youngest age groups, efforts should focus on sustaining and even increasing the existing high vaccination coverage.In this respect, Finland has set an important example of how to successfully eliminate mumps by reaching and maintaining vaccination coverages of more than 95% [39].

WHO launches World health report 2013
Eurosurveillance editorial team (eurosurveillance@ecdc.europa.eu)Chapter 5 proposes a set of actions by which the research community, national governments, donors, civil society and international organisations can support the research that is needed to reach universal health coverage.

Figure 1
Figure 1Invasive group A streptococcal cases notified by month and year in Ireland, January 2006-June 2013 (n=607)

Figure 2
Figure 2Age-specific incidence rate of invasive group A streptococcal infections per 100,000 population by five-year age groups, Ireland, 2012 and averaged over the period 2006-11 Second dose | WFS First dose | EFS Second dose | EFS Our analysis contained mumps diagnoses billed between 1 January 2007 and 31 December 2011.Data from the states of Baden-Württemberg (2007 only) and Hesse (2007-11) had to be excluded due to incomplete information.After the exclusion, the data set covered 79% of the population living in Germany during 2008 to 2011 and 68% during 2007.

Figure 2
Figure 2Mean annual mumps incidence among males and proportion of mumps-associated orchitis among all male mumps cases per age group, based on ambulatory statutory health insurance claims data, Germany 2007-2011 group (years) WFS | mumps incidence in males EFS | mumps incidence in males WFS | proportion of orchitis cases EFS | proportion of orchitis cases statutory health insurances.Of those, 1,995 (32.6%) were claimed during the outbreak period with the peak occurring in the first quarter of 2011 (n=752; 37.7%).

Figure 5
Figure 5Vaccination status per age group among mumps cases with known status, reported via the voluntary ad-hoc notification system, Bavarian outbreak 2010/2011 (n=217) The annual number of patients born in Georgia rose from ca. two cases in 2006 to 2010 to five in 2011 and 26 in 2012 (Figure 2); for those born in the Russian Federation from ca. four in 2006 to 14 in 2012; and for those born in Ukraine from two cases in 2007 to four cases in 2012.The number of patients who originated from other parts of the world remained stable, except for those born in Eastern Europe outside the FSU, who doubled from an annual average of four in 2006 to 2008 to eight in 2009 to 2012.

Table
Characteristics of patients with multidrug-resistant tuberculosis identified in 2012, by region of birth, France (n=92) aComparison between total FSU and other countries.Invasive group A streptococcal (iGAS) infections have been notifiable in Ireland since 2004.Incidence rates (2004-2011) have ranged from 0.8 to 1.65 per 100,000.In 2012, the iGAS rate rose to 2.66 per 100,000 and was associated with a high proportion of emm1 isolates.A further increase in January to June 2013 has been associated with increased prevalence of emm3.Public health departments and clinicians have been alerted to this increase.
Very young adolescence was defined as a recorded age at STI diagnosis of between 13 and 15 years.A case reported from more than one of the three surveillance systems was counted only once in the analysis.When duplicates were detected, cases in the microbiological notification system were excluded from the analysis.Epidemiological and behavioural characteristics of STIs among adolescents aged 13-15 years in Catalonia are shown in Table1and the reported STIs in Table2.A total of 27 STI cases were reported during the study period (January 2012 to June 2013).Of these, 13 were reported during the first six months of 2013; in the first half of 2012, nine cases were reported (Table2).This increase was due mainly to the increased number of cases of gonorrhoea.The number of cases with other STIs was very low, making comparisons between the years difficult.Overall, during 2007 to 2012, three syphilis cases (one in 2007, 2011 and 2012) and one gonorrhoea case in 2011 were reported among very young adolescents aged 13-15 years.
STI case-report data from the three surveillance systems are entered into the Public Health Agency of Catalonia's Epidemiological Repository System, allowing complementarity of variables and capture of cases.Confidentiality and data protection are assured[3].STI case definitions used for surveillance reporting are standardised, as the European Union definitions are used[4].GonorrhoeaA total of 10 very young adolescents (13-15 years) with gonorrhoea were reported to the Public Health Agency of Catalonia during January 2012 to June 2013.Seven were boys and seven were born outside of Spain, in Latin America and the Caribbean.Sexual orientation (heterosexual) was known for only four of the cases.Paediatricians notified four of the 10 cases.

Table 1
Epidemiological and behavioural characteristics of adolescents aged 13-15 years with sexually transmitted infections, Catalonia, Spain, January 2012-June 2013 (n=27) HIV: human immunodeficiency virus; STI: sexually transmitted infection.a Information on country of birth was not available for all cases.

Table 2
Sexually transmitted infections reported among adolescents aged 13-15 years, Catalonia, Spain, January 2012-June 2013 Mumps vaccination coverage rates for first and second dose at school entry (age 5-7 years) in Western and Eastern federal states, Germany, 1998-2010 Our dataset included the patient's anonymous unique identifier (ID), sex, month/year of birth, district/state of residence, state of billing physician's practice, ICD-10 code, quarter/year of diagnosis, reliability of diagnosis (suspected, confirmed, excluded or recovered), and type of diagnosis (current state, previous state, unknown or not provided).EFS: Eastern federal states; WFS: Western federal states.

Table
Annual mumps incidence, incidence rate ratio and p value, by age group, based on ambulatory statutory health insurance claims data,Germany, 2007Germany,  -2011 (n=32,330)    (n=32,330) CI: confidence interval; IRR: incidence rate ratios.Significant IRR, 95%CI and p values are shown in bold.

Bavarian outbreak 2010/11: Comparison of ASHIP data with ad-hoc notification data
Title: Mumps incidence per age group based on ambulatory statutory health insurance claims data during the 2010/11 outbreak period (n=1,995) and non-outbreak period (n=4,116),Bavaria, 2007Bavaria,  -2011Point estimates showed 95% confidence intervals spanning a range of less than 0.05 (not shown in figure).Vaccination status per age group among mumps cases with known status, reported via the mandatory notification system, Eastern federal states,2007-2011 (n=284) suggesting an age-shift over time.This observation is mirrored by the Bavarian outbreak 2010/11 where highest incidences were seen among 15 to 29 year-olds; the finding is further in line with recent outbreak reports from other countries with long-established vaccination programmes[10][11][12][13]15].One reason could be that Figure 4 1 1.European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden Eurosurveillance editorial team.WHO launches World health report 2013.Euro Surveill.2013;18(33):pii=20559.Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20559 Article published on 15 August 2013 On 15 August 2013, the World Health Organization (WHO) launched the 'World health report 2013: Research for universal health coverage'[1].The report addresses funding organisations, researchers (active and in the future) and policy makers.It shows how countries, when developing a system for universal health coverage, can use research to determine what health issues should be addressed, how a system should be structured and how to measure progress according to their specific health situation.The report is divided in five chapters: Chapter 1 deals with the role of research for universal health coverage, for the provision of, and access to, high-quality health services; and financial risk protection for people who need to use these services.Chapter 2 gives an overview of the changing landscape of research while Chapter 3 presents examples of studies that show how research can address some of the major questions about achieving universal health coverage, and can deliver results that have influenced, or could influence, policy and health outcomes.Chapter 4 describes the essential functions of national health research systems, namely: to set research priorities, to develop research capacity, to define norms and standards for research, and to translate evidence into practice.It presents mechanisms to stimulate and facilitate research for universal health coverage -monitoring (national and international observatories), coordination (information-sharing, collaborative research studies) and financing (raising and distributing funds to support global and national research priorities).