GERMANY Population 1999: Population 2000: Area: km 2

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1 WHO Surveillance Programme for Control of Foodborne Infections and Intoxications in Europe Country Reports: Germany BfR GERMANY Population 1999: Population 2: Area: km 2 1. General Information The data contained in this report for Germany (country abbreviation: DE) were collected under the Federal Communicable Diseases Act which was in place until No specific notification of foodborne diseases by pathogen was required. However, all cases of infectious enteritis caused by Salmonella species other than S.Typhi or S. Paratyphi or by other micro-organisms were notifiable and considered to be foodborne. Since 1998, enteric infections caused by EHEC have been notifiable as well. The Federal Communicable Diseases Act foresaw that even suspect cases should be reported; however, unless the causal agent was identified, this was often not done. This pertained in particular to cases of diseases in which the etiological agent was difficult to identify or in which the identification of the pathogen required specific methods not commonly used during routine examinations of samples. Yersinia enterocolitica, Campylobacter sp., and Vibrio parahaemolyticus are examples of such micro-organisms. The same applies for cases in which toxins are involved, such as those produced by Staphylococcus aureus and Clostridium perfringens. The main problem remains that only a small number of cases are diagnosed microbiologically due to the lack of individual therapeutical consequences. Other foodborne communicable diseases notifiable according to the old Federal Communicable Diseases Act in Germany included botulism, brucellosis, trichinellosis and hepatitis A. Toxoplasmosis and listeriosis were notifiable in congenital cases only; thus, they are not included in the tables of foodborne diseases.

2 Figure DE 1 Notification system GERMANY In addition to the statutory reporting of diseases notifiable according to the Communicable Diseases Act, a "Surveillance Programme of Foodborne Infections and Microbial Intoxications" has existed since Through this programme, considerable information on the epidemiology of foodborne disease has been obtained. This programme has replaced a salmonellosis surveillance programme in order to obtain epidemiological information on all foodborne diseases prevalent in Germany. It uses formats and procedures compatible with the WHO Surveillance Programme and is operated on a voluntary basis. In the case of an outbreak, the respective local public health administration sends all epidemiological details to the Federal Contact Point at the Robert Koch Institut (Federal Institute for Infectious and Non-communicable Diseases, RKI), where the information is collated and evaluated. The operation of the German reporting system up to the year 2 is illustrated in Figure DE 1. The graph also shows the voluntary surveillance system of foodborne disease. Surveillance of infectious diseases in Germany has since been reorganized, and the Federal Communicable Diseases Act was replaced by the Protection against Infections Act as of 1 January 21. The new act specifies the diseases to be reported by physicians and laboratory results for certain pathogens to be reported by laboratories. Outbreaks of foodborne or other dangerous diseases are now also subject to mandatory reporting

3 2. Statutory notification In 1999 and 2, a total of 2279 and cases of foodborne diseases were notified through the mandatory notification system. In 45% and 42% of the infectious enteritis cases notified in 1999 and 2, the cause was identified. As in previous years, salmonellosis was the most frequently notified foodborne disease, accounting for 43% and 4% of the notified cases in the years mentioned (Table DE 1). Figure DE 2 gives an overview of the foodborne diseases notified between 1993 and 2. Table DE 1 Foodborne diseases notified GERMANY Disease cases Incidence rate cases Incidence rate Salmonellosis (excl. S. typhi and S paratyphi) Staphylococcosis Botulism Campylobacteriosis Shigellosis E.coli enteritis Cholera Brucellosis Bacillus cereus Hepatitis A Other viral enteritis Echinococcosis Trichinellosis Giardiasis Amoebiasis Infectious Enteritis of unknown origin Total

4 Figure DE 2 cases Shigellosis Foodborne Diseases Notified GERMANY Salmonellosis (excl. S.typhi and S.paratyphi) Hepatitis A Infectious enteritis of unknown origin salmonellosis and other infectious enteritis cases 3. Epidemiologically investigated incidents In 1999, 13 of foodborne diseases involving 1699 cases were investigated. In 2, 93 with 1334 cases were examined. This continues the downward trend observed since 1997 (Figure DE 3). On average, the investigated in 1999 and 2 lasted 4,9 and 4,7 days and involved 13 and 15 cases (Table DE 2). The age group most frequently affected was the group of 15 to 6 year old persons. Ten percent and 15% of cases in 1999 and 2 were hospitalised. Around 88% of these hospitalisations were due to S. Enteritidis infections. Moreover, the one death due to a foodborne disease outbreak reported in 1999 was caused by S. Enteritidis. The most frequently reported clinical symptoms were diarrhoea, followed by nausea and vomiting (Table DE 3)

5 Figure DE Foodborne Disease Outbreaks GERMANY Outbreaks Cases cases Table DE 2 Duration and size of, incubation time and illness in foodborne disease investigated GERMANY Mean duration of outbreak (d) 4,9 (range 1-27) 4,7 (range 1-31) Mean incubation time (d) 1,3 (range,1-17) 1,2 (range -17) Mean duration of illness (d) 4,3 4,7 (range -43) Mean no. of cases 13,1 (range 3-19) (range -41,6) 15,2 (range 2-7) - 5 -

6 Table DE 3 Morbidity, mortality and clinical symptoms of foodborne disease GERMANY persons at risk persons at risk -4 years old persons at risk 5-14 years old persons at risk 15-6 years old persons at risk > 6 years old persons ill persons ill -4 years old persons ill 5-14 years old persons ill 15-6 years old persons ill > 6 years old 19 persons hospitalised persons hospitalised -4 years old 5 13 persons hospitalised 5-14years old persons hospitalised 15-6 years old persons hospitalised > 6 years old 1 persons dead 1 persons dead -4 years old persons dead 5-14 years old persons dead 15-6 years old 1 persons dead > 6 years old Clinical symptoms persons with nausea persons vomiting persons with diarrhoea persons with abdominal pain persons with fever persons with neurological symptoms persons with cardiovascular symptoms 21 persons with other symptoms The number of laboratory tests carried out in connection with the investigations of foodborne disease in 1999 and 2 is shown in Table DE 4. While in 98% and 99% of the investigated in 1999 and 2 laboratory tests were carried out on samples from ill persons, suspected food was tested only in 39% and 45% of investigated in 1999 and 2 respectively

7 Table DE 4 Laboratory tests carried out during investigations of foodborne disease GERMANY Laboratory tests ill people tested ill people positive 972 (6%) 826 (63%) healthy people tested healthy people positive 122 (12%) 18 (12%) food handlers tested 56 5 food handlers positive 6 (11%) 1 (2%) suspected food tested suspected food positive 38 (21%) 36 (14%) other food tested 38 other food positive 1 (3%) environmental tests environmental tests positive 15 (3%) 9 (1%) 3.1 Causative agents The causative agent was identified in 8% and 83% of the foodborne disease investigated in 1999 and 2 respectively. In 97% and 96% of the in which the causative agent was identified, the agent was confirmed by laboratory diagnosis. S. Enteritidis was responsible for 65% and 62% of the in 1999 and 2, followed by Norwalk virus in 1999 (5,4%) and S. Typhimurium in 2 (1,8%) (Table DE 5). Figure DE 4 gives an overview of the causative agents involved in foodborne disease investigated between 1993 and 2. An overview of the Salmonella serotypes isolated in foodborne disease investigated between 1993 and 2 is shown in Figure DE 5. Table DE 5 Foodborne disease investigated by causative agents GERMANY Causative agent cases cases Bacillus cereus Campylobacter sp Cl. perfringens 1 4 E. coli 1 22 Norovirus Rotavirus 1 12 S. Enteritidis S. Hadar 1 24 S. Typhimurium

8 Salmonella sp Staph. aureus 1 6 Unknown agent Total Figure DE Foodborne Disease Outbreaks by Causative Agents GERMANY S. Eenteritidis Bacillus cereus Campylobacter sp. Cl. botulinum Cl. perfringens Staph. aureus E. Coli Shigella sonnei S. Typhimurium Salmonella sp. Rotavirus Other viruses Other agents Unknown agents S. Enteritidis Figure DE 5 Salmonella Serotypes Identified in Foodborne Disease Outbreaks Investigated GERMANY cases S. enteritidis cases S. Typhimurium S. Infantis S. Thompson Others/not specified S. Enteritidis - 8 -

9 3.2 Incriminated foods The food responsible for foodborne disease investigated in 1999 and 2 was identified in 78% of the. Identification was based on laboratory confirmation of the causative agent in the food in 18% and 3% of these in 1999 and 2 respectively. The most frequently incriminated foods were eggs and egg products in 1999 (13% of ), and puddings and creams in 2 (16% of ). Details of the foodborne diseases investigated in 1999 and 2 are shown in Table DE 6, while Figure DE 6 gives an overview of the foodborne disease investigated between 1993 and 2 by incriminated food. Table DE 6 Foodborne disease investigated by incriminated foods GERMANY Incriminated food cases cases Eggs, egg products Mayonnaise, dressings Fancy cakes Sweets 1 34 Ice cream 2 18 Puddings, creams Milk Milk products 5 6 Cereal products 1 11 Pasta Fish 2 1 Fish products 1 33 Meat Raw minced meat Pork Chicken Turkey Other poultry Sausages Meat products Meat salads 1 6 Potato salad Soups, gravies Other Unknown Total

10 Figure DE 6 * Foodborne Disease Outbreaks by Incriminated Food GERMANY Milk, milk products Cheese Meat and meat products Poultry and poultry products Fish and fish products, molluscs Cakes, puddings, ice-cream Mayonnaise, sauces,salads Other egg products Vegetable products Composed food Other Unknown * includes only in which the food was microbiologically confirmed Information on how the incriminated food had been marketed was provided for 51% and 56% of the investigated in 1999 and 2. In 42% and 51% of these, the food had been marketed non-packaged. Information on the treatment of the incriminated food before the final preparation is available for 32% and 45% of the in 1999 and 2. The most frequently reported treatment of incriminated food was refrigeration (13% in 1999, 23% in 2). Information on how the incriminated food had been served and eaten is available for 54% and 59% of the in 1999 and 2. In 25% and 31% of these, the incriminated food had been served and eaten raw, i.e. without further preparation (Table DE 7)

11 Table DE 7 Methods of marketing and processing of food incriminated investigated GERMANY Methods of marketing and processing cases cases Marketing of incriminated food Non-packaged Packaged Unknown Total Treatment before final preparation Cooked Frozen Pasteurised Refrigerated Salted/pickled Sterilised 1 6 Unknown Total Served and eaten Heated Kept warm Other Raw Reheated 1 35 Supplied in thermophores Unknown Total Place of contamination or consumption The place where the incriminated food had been contaminated was identified in 48% of the investigated in 1999 and 2. The most frequently reported place of contamination was the food processing establishment, mentioned in 59% and 87% of the with an identified place of contamination (Table DE 8). An overview of the places of contamination implicated in foodborne disease reported between 1993 and 2 is given in Figure DE 7. The place where the incriminated food had been consumed was identified in 93% and 98% of the investigated in 1999 and 2. The most frequently reported place of consumption was the private home, mentioned in 43% and 36% of the with an identified place of consumption (Table DE 9). An overview of the places of consumption implied in foodborne disease reported between 1993 and 2 is given in Figure DE

12 Table DE 8 Foodborne disease by place of contamination GERMANY Place of contamination cases cases Farm Food processing establishment Medical care facility 1 3 Private home Restaurant/hotel 1 5 Retail store Unknown Total Figure DE Foodborne Disease Outbreaks by Place of Contamination GERMANY * * 1998 includes only in which the food was microbiologically confirmed linked to food proc. establ. and unknown places Farm Private home Restaurant/hotel Medical care fac. School/ kindergarten Mass catering f. spec. groups Canteen Ambulant service Retail store Caterer Camping Other Food processing est. Unknown

13 Table DE 9 Foodborne disease investigated by place of consumption GERMANY Place of consumption cases cases Camping 1 1 Canteen Mass catering for specific groups Medical care facility Other Picnic Private home Restaurant/hotel School/kindergarten Unknown Total Figure DE 8 Foodborne Disease Outbreaks by Place of Consumption GERMANY Private home Medical care facility Restaurant/Hotel School/Kindergarten Mass catering f. spec. groups Canteen Ambulant service Retail store Picnic Camping Other Unknown 1998 includes only in which the food was microbiologically confirmed

14 3.4 Contributing factors The factors contributing to foodborne disease were reported in 48% of the investigated in 1999 and 2. The most frequently reported factor was the use of contaminated ingredients, specified in 51% and 42% of with identified contributing factors in 1999 and 2 respectively. Amongst other contributing factors, improper storage was reported for 31% and 6% of the with identified contributing factors in the years mentioned (Table DE 1). Figure DE 9 gives an overview of the contributing factors reported between 1993 and 2. Table DE 1 Foodborne disease by contributing factors GERMANY Contributing factors cases cases Most important contributing factors Contamination by infected person Contamination by infective equipment Use of contaminated ingredients Food obtained from unsafe source 3 24 Improper storage Inadequate cooking Inadequate hot holding 2 33 Inadequate reheating 4 38 Inadequate refrigeration Inadequate cooling after heating Other factors Unknown Total Other contributing factors Contamination by infected person Use of contaminated ingredients Improper storage Inadequate hot holding Inadequate reheating 1 5 Inadequate refrigeration 3 3 Total

15 Figure DE Foodborne Disease Outbreaks by Contributing Factors GERMANY with unknown contributing factors 12 Inadequate refrigeration Inadequate hot holding Inadequate cooling after heating Inadequate reheating Food obtained from unsafe source Using of contaminated ingred. Contamin./infected persons Contamin./infected equipment Inadequate cooking Improper storage Other factors Unknown Additional Information The website of the RKI at provides information on the mandate, structure and activities of the institute. The RKI publishes on a weekly basis the Epidemiologisches Bulletin, which includes information on communicable as well as non-communicable diseases and other relevant health issues. It is available online at For further reference on national and international data on foodborne diseases, please visit the web page