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Vaccine preventible diseases in Germany
Gernot Rasch
Ständige Impfkomission - STIKO - Německá pediatrická společnost, SRN

Vaccination is the most successful and most cost-effective method of primary prevention of infektious diseases. Important prerequisites for the successful implementation of vaccination programs exist in Germany as in other industrialized countries. Highly effective vaccines, tested and approved by state authorities, are available. Vaccinations are paid by health insurances or employers with the exception of vaccinations arranged for private travel. Vaccination is voluntary but all important vaccinations are recommended by the STIKO (Standing Committee on Vaccination) for children and adolescents or for specific high risk groups. Legal guarantees for compensation of rare cases, if people suffer permanent damage by vaccination, have been implemented for all vaccinations recommended by the Federal States. Post-marketing surveillance for complications of vaccines is generally done by the Paul-Ehrlich-Institute which is also responsible for the testing and licensing of vaccines. However this system is not optimal and does not allow to estimate valid rates of side effects. The new law for the control of infectious diseases (IFSG), which will be implemented in the year 2001 makes severe vaccine side effects reportable and will significantly improve the surveillance of vaccine reactions. In Germany, vaccination coverage is sub-optimal despite favorable prerequisites. There are various reasons for the insufficient results. Neither legal compulsion nor specific requirements are existing for entry into school or day care centers. Most vaccinations are not provided or organized by the Community Health Service. More than 90% of infant immunization is provided through private practitioners.

Therefore each vaccination requires active co-operation of the person subject to be vaccinated (or the parents) and the physician. There is too little „ incentive" for people to get vaccinated and the lack in public knowledge of the benefit of vaccinations. Even some physicians are insufficiently convinced or do not convey their belief to patients sufficiently. Pediatricians and general practitioners are often insufficiently prepared to actively approach their patients about updating their vaccination status. Moreover, the remuneration for vaccination is regarded as insufficient by many physicians, which does not help to increase vaccination activities, especially if the time needed to discusss the issue is taken into consideration.

Regional vaccination registers, which would allow the active follow up of non immunized persons by the Community Health Services, do not exist. Therefore, healthy adults, adolescents and children - who are not seen by a doctor on a regular basis - have rarely checked and updated their vaccination status. Local or regional facility for active call-up and recall for immunization are not existing. Therefore surveillance of vaccine coverage can not be considered optimal at all. As a result of the mentioned conditions vaccination coverage in Germany is too low for effective control as well as for elimination for vaccine preventable diseases.

Nevertheless the positive result of the vaccination program in Germany is impressive. Tetanus (in children), diphtheria and poliomyelitis are almost eliminated. The incidence of septic Hib-infections and of measles, mumps and rubella has decreased significantly. However, the coverage and timeliness for MMR vaccination is not yet sufficient for the target of elimination of measles. We still have an insufficient reduction in morbidity of pertussis and hepatitis B although the vaccina coverage in infants now has reached about 80%.