Ralf Reintjes

Publications of Ralf Reintjes

• Evaluating health systems' preparedness for emerging infectious diseases: a novel conceptual and analytic framework.

  Authors: Ralf Krumkamp, Sandra Mounier-Jack, Amena Ahmad, Ralf Reintjes, Richard Coker

  Health policy (Amsterdam, Netherlands). 12/2010; 98(2-3):91-7.

  In this article we present a novel conceptual framework for systematically assessing the national health system capacity to respond to pandemic influenza. This framework helps to determine how healthIn this article we present a novel conceptual framework for systematically assessing the national health system capacity to respond to pandemic influenza. This framework helps to determine how health systems and pandemic programmes interact, whether, where and which weak points exist, and how and where pandemic response health programmes can be improved effectively. This new conceptual framework draws upon two existing approaches for assessment and evaluation, the Systemic Rapid Assessment Toolkit (SYSRA) and the Hazard Analysis of Critical Control Points (HACCP). SYSRA is a systematic approach to analyse the interplay between communicable disease programmes and the broader health systems context within which they operate and the HACCP methodology builds upon a systematic analysis of process steps within a programme in order to identify likely hazards and to develop control measures to address them. The analytical framework that we have developed from the novel conceptualisation is simple, can be applied rapidly, and should, we believe, be low cost to implement. Thus, this provides a means for developing a contextual understanding of the broader health system in which a pandemic infectious disease programme operates, and for identifying frailties in programmes that need to be responded to.

• Controlling SARS: a review on China's response compared with other SARS-affected countries.

  Authors: Amena Ahmad, Ralf Krumkamp, Ralf Reintjes

  Tropical medicine & international health : TM & IH. 07/2009;

  Objective To summarise the major control measures implemented by severe acute respiratory syndrome (SARS)-affected countries and to compare distinctive features of the Chinese approach to otherObjective To summarise the major control measures implemented by severe acute respiratory syndrome (SARS)-affected countries and to compare distinctive features of the Chinese approach to other affected Asian countries and Canada. Method Literature review. Results The realisation in March 2003 that SARS was spreading led affected countries to introduce measures such as rapid dissemination of information, early case detection and isolation, tracing and quarantining of SARS contacts, traveller screening, raising public awareness of risk and institution of stricter infection control in health care settings. SARS became a notifiable disease in China in mid-April 2003, after which introduction of efficient nationwide control measures led to containment within 2 months. Countries differed in the timeliness of implementing control measures, the mode and extent to which these were enforced and in the resources available to do so. Conclusion SARS challenged the political and public health systems of all affected countries. It demanded rapid and decisive action to be taken, yet the comparison shows how difficult this was for an unknown new disease. Guangdong reacted rapidly but this pace was not continued by China for some time, which facilitated national and international spread. Once the Chinese government changed its policy, it developed an impressive control strategy involving the public which culminated in containment. The significance of timely information was perhaps the main lesson which the SARS epidemic taught.

• Evaluation of national pandemic management policies-A hazard analysis of critical control points approach.

  Authors: Ralf Krumkamp, Amena Ahmad, Annette Kassen, Lulu Hjarnoe, Ahmed M Syed, Arja R Aro, Ralf Reintjes

  Health policy (Amsterdam, Netherlands). 04/2009;

  Analyses of pandemic preparedness policies revealed weaknesses in control systems of European nations. This reinforces the need to support countries in their endeavours to prevent and containAnalyses of pandemic preparedness policies revealed weaknesses in control systems of European nations. This reinforces the need to support countries in their endeavours to prevent and contain pandemics. A Hazard Analysis and Critical Control Points (HACCP) was applied to a generic plan to identify weaknesses in pandemic management policies, in order to develop recommendations for improving national pandemic management systems. Policy components considered in our analysis are command and control, early case detection and disease surveillance, and community containment management. The main critical areas identified in national pandemic control were: communication systems among all institutions and levels involved in pandemic management, guidelines and regulations describing how key personal and institutions should operate during a pandemic, training and dissemination of information to health care personnel involved in outbreak management. The HACCP analysis highlighted the need for agreed communication structures, clear division of responsibilities and harmonised policy guidelines at all levels of pandemic management. Being prepared is the key to successfully coordinate and implement response measures when a pandemic emerges.

• Impact of public health interventions in controlling the spread of SARS: Modelling of intervention scenarios.

  Authors: Ralf Krumkamp, Hans-Peter Duerr, Ralf Reintjes, Amena Ahmad, Annette Kassen, Martin Eichner

  International journal of hygiene and environmental health. 06/2008;

  A variety of intervention measures exist to prevent and control diseases with pandemic potential like SARS or pandemic influenza. They differ in their approach and effectiveness in reducing theA variety of intervention measures exist to prevent and control diseases with pandemic potential like SARS or pandemic influenza. They differ in their approach and effectiveness in reducing the number of cases getting infected. The effects of different intervention measures were investigated by a mathematical modelling approach, with comparisons based on the effective reproduction number (R(e)). The analysis showed that early case detection followed by strict isolation could control a SARS outbreak. Tracing close contacts of cases and contacts of exposed health care workers additionally reduces the R(e). Tracing casual contacts and measures aiming to decrease social interaction were less effective in reducing the number of SARS cases. The study emphasizes the importance of early identification and isolation of SARS cases to reduce the number of people getting infected. However, doing so transfers cases to health care facilities, making infection control measures in hospitals essential to avoid nosocomial spread. The modelling approach applied in this study is useful for analysing interactions of different intervention measures for reducing the R(e) of SARS.

• Case-case study of a Salmonella outbreak: an epidemiologic method to analyse surveillance data.

  Authors: Ralf Krumkamp, Ralf Reintjes, Martin Dirksen-Fischer

  International journal of hygiene and environmental health. 03/2008; 211(1-2):163-7.

  Routine infectious disease surveillance data has to be analysed quickly in order to prevent further disease transmission. This can be done by using epidemiological studies, such as case-controlRoutine infectious disease surveillance data has to be analysed quickly in order to prevent further disease transmission. This can be done by using epidemiological studies, such as case-control studies. However, these studies are complex to perform and susceptible for biases. An alternative is the case-case study design which is less prone to such limitations. So far mainly methodological publications of this study design exist. In this investigation, outbreak cases are compared with cases infected with the same disease. A Salmonella outbreak was analysed with a case-case study design in order to test the applicability of this method. The analysis showed significant associations to the consumption beef (OR 11.8; 95% CI 2.4-66.7; p<0.001) and pork (OR 8.44; 95% CI 1.7-46.4; p<0.001). A case-control study on the same outbreak confirmed these results. An infected control group is very comparable to the outbreak cluster, which limits selection and recall bias. However, the calculated OR has to be interpreted in context with the study design. The case-case study design has proven to be a useful tool to analyse surveillance data. It was easy to perform and had methodological benefits.

• Nasal Staphylococcus aureus carriage is not a risk factor for lower-airway infection in young cystic fibrosis patients.

  Authors: Sabine Ridder-Schaphorn, Felix Ratjen, Angelika Dübbers, Johannes Häberle, Sabine Falk, Peter Küster, Antje Schuster, Uwe Mellies, Brigitte Löwe, Ralf Reintjes, Georg Peters, Barbara C Kahl

  Journal of clinical microbiology. 10/2007; 45(9):2979-84.

  Staphylococcus aureus is one of the first pathogens which often persistently infect the airways of cystic fibrosis (CF) patients. Nasal S. aureus carriage is a risk factor for S. aureus infections inStaphylococcus aureus is one of the first pathogens which often persistently infect the airways of cystic fibrosis (CF) patients. Nasal S. aureus carriage is a risk factor for S. aureus infections in non-CF patients. Topical treatment strategies successfully eradicate nasal S. aureus carriage, thereby decreasing S. aureus infection. A prospective longitudinal multicenter study was conducted to assess whether nasal carriage represents a risk factor for S. aureus colonization of the oropharynx in young CF patients. Cross-sectional analysis revealed a significantly higher prevalence of S. aureus-positive nasal (28/80 [35%] versus 20/109 [18%]; P < 0.01) and oropharyngeal (35/80 [44%] versus 20/109 [18%]; P < 0.001) cultures in children with CF compared to a control group. The first site of S. aureus detection was the nose in 6 patients and the oropharynx in 14 patients, respectively. Longitudinal analysis demonstrated a significantly higher S. aureus prevalence (61/62 [98%] versus 47/62 [76%]; P < 0.001) and persistence (46/62 [74%] versus 31/62 [50%]; P < 0.01) in the oropharynx than in the nose. In CF patients, the oropharynx, and not the nose, was the predominant site of S. aureus infection and persistence. Hence, it is unlikely that CF patients will benefit from topical treatment strategies to eradicate nasal carriage.

• Benchmarking national surveillance systems: a new tool for the comparison of communicable disease surveillance and control in Europe.

  Authors: Ralf Reintjes, Martina Thelen, Ralf Reiche, Agnes Csohán

  European journal of public health. 09/2007; 17(4):375-80.

  BACKGROUND: Communicable diseases do not respect national boundaries and are important challenges to health internationally. Considerable variation exists in the structure and performance ofBACKGROUND: Communicable diseases do not respect national boundaries and are important challenges to health internationally. Considerable variation exists in the structure and performance of surveillance systems for communicable disease prevention and control. European Union (EU) countries should share ideas to improve the quality of surveillance systems. The study aims to support the improvement and integration of surveillance systems of communicable diseases in Europe while using benchmarking for the comparison of national surveillance systems. METHODS: Surveillance systems from England and Wales, Finland, France, Germany, Hungary, and The Netherlands were described and analysed. After comprehensive data collection and validation by several European public health (PH) experts, a descriptive data analysis was carried out. Benchmarking processes were performed with selected criteria (e.g. case definitions, early warning applications, and outbreak investigations). After the description of benchmarks, best practices were identified and described. RESULTS: Benchmarking of national surveillance systems is applicable as a new tool for the comparison of communicable disease control in Europe. The countries included in the study have in general well-functioning communicable disease control and prevention systems. Nevertheless, there are different strengths and weaknesses in various countries. Practical examples from the various surveillance systems were demonstrated and recommendations were given to policy makers. CONCLUSION: A gold standard of surveillance systems in various European countries is very difficult to achieve because of heterogeneity (e.g. in disease burden, personal, and financial resources). However, to improve the quality of surveillance systems across Europe, it will be useful to benchmark the surveillance systems of all EU member states.

• 2nd-generation HIV surveillance and injecting drug use: uncovering the epidemiological ice-berg.

  Authors: Ralf Reintjes, Lucas Wiessing

  International journal of public health. 02/2007; 52(3):166-72.

  OBJECTIVES: HIV/AIDS surveillance methods are under revision as the diversity of HIV epidemics is becoming more apparent. The so called "2nd generation surveillance (SGS) systems" aim to enhanceOBJECTIVES: HIV/AIDS surveillance methods are under revision as the diversity of HIV epidemics is becoming more apparent. The so called "2nd generation surveillance (SGS) systems" aim to enhance surveillance by broadening the range of indicators to prevalence, behaviors and correlates, for a better understanding and a more complete and timely awareness of evolving epidemics. METHODS: Concepts of HIV SGS are reviewed with a special focus on injecting drug users, a major at-risk and hard to reach group in Europe, a region with mainly low or concentrated epidemics. RESULTS: The scope of HIV/AIDS surveillance needs to be broadened following principles of SGS. Specifically for IDUs we propose including hepatitis C data as indicator for injecting risk in routine systems like those monitoring sexually transmitted infections and information on knowledge and attitudes as potential major determinants of risk behavior. CONCLUSIONS: The suggested approach should lead to more complete and timely information for public health interventions, however there is a clear need for comparative validation studies to assess the validity, reliability and cost-effectiveness of traditional and enhanced HIV/AIDS surveillance systems.

• [The impact of the proportion of qualified nursing personnel on the incidence of pressure ulcers in nursing homes]

  Authors: Johann Popp, Franz Pröfener, Jens Stappenbeck, Ralf Reintjes, Petra Weber

  Pflege. 11/2006; 19(5):303-7.

  In Germany a minimal quota of 50% professionally qualified nursing personnel is statutory for the care of nursing home inhabitants. The influence of this quota on the quality outcome of nursing careIn Germany a minimal quota of 50% professionally qualified nursing personnel is statutory for the care of nursing home inhabitants. The influence of this quota on the quality outcome of nursing care is controversially discussed. The study investigated the question, whether there is an association between the proportion of qualified personnel and the incidence of pressure ulcers in nursing homes. A historical cohort study was performed. Incidence data were taken from a routine survey on pressure ulcers. Nursing homes participating in this survey were asked for information about their proportion of qualified personnel and some additional factors that could possibly influence the incidence of bedsores. Included nursing home inhabitants (n = 2813) were divided into three groups according to whether they have been cared for with a low (< 50%), medium (50-60%) or high (> or = 60%) proportion of qualified personnel. Multivariate logistic regression models were calculated. Comparing medium to low proportion of qualified personnel, an odds ratio of 1.5 (p = 0.455), comparing high to low proportion, an odds ratio of 0.8 (p = 0.703) and comparing high to medium proportion, an odds ratio of 0.54 (p = 0,09) was calculated. The study question can not be answered by the contradictory results.

• Automated DNA sequence-based early warning system for the detection of methicillin-resistant Staphylococcus aureus outbreaks.

  Authors: Alexander Mellmann, Alexander W Friedrich, Nicole Rosenkötter, Jörg Rothgänger, Helge Karch, Ralf Reintjes, Dag Harmsen

  PLoS medicine. 03/2006; 3(3):e33.

  BACKGROUND: The detection of methicillin-resistant Staphylococcus aureus (MRSA) usually requires the implementation of often rigorous infection-control measures. Prompt identification of an MRSABACKGROUND: The detection of methicillin-resistant Staphylococcus aureus (MRSA) usually requires the implementation of often rigorous infection-control measures. Prompt identification of an MRSA epidemic is crucial for the control of an outbreak. In this study we evaluated various early warning algorithms for the detection of an MRSA cluster. METHODS AND FINDINGS: Between 1998 and 2003, 557 non-replicate MRSA strains were collected from staff and patients admitted to a German tertiary-care university hospital. The repeat region of the S. aureus protein A (spa) gene in each of these strains was sequenced. Using epidemiological and typing information for the period 1998-2002 as reference data, clusters in 2003 were determined by temporal-scan test statistics. Various early warning algorithms (frequency, clonal, and infection control professionals [ICP] alerts) were tested in a prospective analysis for the year 2003. In addition, a newly implemented automated clonal alert system of the Ridom StaphType software was evaluated. A total of 549 of 557 MRSA were typeable using spa sequencing. When analyzed using scan test statistics, 42 out of 175 MRSA in 2003 formed 13 significant clusters (p < 0.05). These clusters were used as the "gold standard" to evaluate the various algorithms. Clonal alerts (spa typing and epidemiological data) were 100% sensitive and 95.2% specific. Frequency (epidemiological data only) and ICP alerts were 100% and 62.1% sensitive and 47.2% and 97.3% specific, respectively. The difference in specificity between clonal and ICP alerts was not significant. Both methods exhibited a positive predictive value above 80%. CONCLUSIONS: Rapid MRSA outbreak detection, based on epidemiological and spa typing data, is a suitable alternative for classical approaches and can assist in the identification of potential sources of infection.

• Detection and response to a meningococcal disease outbreak following a youth football tournament with teams from four European countries.

  Authors: Ralf Reintjes, Thomas Kistemann, Laura MacLehose, Martin McKee, Noel Gill, Julius Weinberg, Oliver Schaefer, Ivonne Camaroni, Naomi Fulop, Helmut Brand

  International journal of hygiene and environmental health. 06/2002; 205(4):291-6.

  An outbreak of meningococcal disease, caused by Neisseria meningitidis, occurred following an international youth football tournament in the summer of 1997, affecting individuals from four EuropeanAn outbreak of meningococcal disease, caused by Neisseria meningitidis, occurred following an international youth football tournament in the summer of 1997, affecting individuals from four European countries. This paper describes the outbreak, focusing on international co-operation in detection, investigation, control and follow-up, identifying weaknesses and exploring opportunities for improved co-operation. Data came from interviews, reports and related documents. The detection and management of the outbreak in each country is analysed. Eleven cases were linked to this outbreak and serotyped as C:2a:P1.5. Control measures varied in each country, reflecting different national guidelines. The outbreak illustrated deficiencies in management of international outbreaks but also demonstrated benefits of international co-operation.

• Spatial patterns of diarrhoeal illnesses with regard to water supply structures--a GIS analysis.

  Authors: Friederike Dangendorf, Susanne Herbst, Ralf Reintjes, Thomas Kistemann

  International journal of hygiene and environmental health. 05/2002; 205(3):183-91.

  This paper presents an application of a geographical information system (GIS) in the field of research of drinking water epidemiology. A retrospective study regarding gastrointestinal infections wasThis paper presents an application of a geographical information system (GIS) in the field of research of drinking water epidemiology. A retrospective study regarding gastrointestinal infections was carried out in the Rhine-Berg District (North Rhine-Westphalia, Germany), which is characterised by different drinking water supply structures. The main objective was to examine the hypothesis that spatial variations of diarrhoeal illnesses may be linked with different drinking water sources (groundwater or surface water). We introduced a GIS for storing and analysing the wide range of data sets comprising features of the water supply structure and the epidemiological databases which constitute the basic elements of a surveillance-system for waterborne infectious diseases. GIS-techniques supported the generation of hypotheses regarding disease distribution and causation. The data bases which are routinely available turned out to be of sufficient quantity and quality for running a waterborne disease surveillance-system. Geo-statistical analysis revealed spatial variations in the incidence of diarrhoeal illnesses. Parameters depicting the water supply structures, especially the amount of drinking water produced from surface or groundwater, were correlated with the age-standardised incidence rates of gastrointestinal infections. The correlation models showed a trend of positive linkage between disease incidence and amount of groundwater. We found GIS-techniques extremely useful to carry out area-based correlation studies and to analyse the exposure of populations in drinking water epidemiology.

• Tularemia outbreak investigation in Kosovo: case control and environmental studies.

  Authors: Ralf Reintjes, Isuf Dedushaj, Ardiana Gjini, Tine Rikke Jorgensen, Benvon Cotter, Alfons Lieftucht, Fortunato D'Ancona, David T Dennis, Michael A. Kosoy, Gjyle Mulliqi-Osmani, Roland Grunow, Ariana Kalaveshi, Luljeta Gashi, Isme Humolli

  Emerging infectious diseases. 02/2002; 8(1):69-73.

  A large outbreak of tularemia occurred in Kosovo in the early postwar period, 1999-2000. Epidemiologic and environmental investigations were conducted to identify sources of infection, modes ofA large outbreak of tularemia occurred in Kosovo in the early postwar period, 1999-2000. Epidemiologic and environmental investigations were conducted to identify sources of infection, modes of transmission, and household risk factors. Case and control status was verified by enzyme-linked immunosorbent assay, Western blot, and microagglutination assay. A total of 327 serologically confirmed cases of tularemia pharyngitis and cervical lymphadenitis were identified in 21 of 29 Kosovo municipalities. Matched analysis of 46 case households and 76 control households suggested that infection was transmitted through contaminated food or water and that the source of infection was rodents. Environmental circumstances in war-torn Kosovo led to epizootic rodent tularemia and its spread to resettled rural populations living under circumstances of substandard housing, hygiene, and sanitation.

• Communicable disease outbreaks involving more than one country: systems approach to evaluating the response

  Authors: Laura MacLehose, Helmut Brand, Ivonne Camaroni, Naomi Fulop, O Noel Gill, Ralf Reintjes, Oliver Schaefer, Martin McKee, Julius Weinberg