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Consequences of the ban of by-products from terrestrial animals in livestock feeding in Germany and the European Union: alternatives, nutrient and energy cycles, plant production, and economic aspects.

Consequences of the ban of meat and bone meal (MBM) and animal fat with regard to livestock feeding, cropping, ecology and economy where investigated with an inter-disciplinary approach for Germany and the European Union. Calculations were made for different production systems with pigs and poultry on the basis of statistical data for the production and for the feed markets as well as from requirement data for the respective species and production system. (1.) The ban of MBM from feeding caused a need for alternative protein sources. If all the amount of protein from MBM is to be replaced by soybean meal, in Germany and the EU about 0.30 and 2.30 x 10(6) t would be needed each year (supplementary amino acids not considered). Alternatively, doubling the grain legume acreage in Germany to about 420,000 ha would supply a similar amount of protein. A wider application of phase feeding with adjusted dietary amino acid concentrations, however, would allow for saving protein to an extent which is similar to the amount of protein that was contributed by MBM in recent years. Thus, the ban is a minor problem in terms of ensuring amino acid supply. (2.) However, alternative plant ingredients cannot compensate for the gap in P supply that is caused by the ban. An additional demand for inorganic feed phosphates of about 14,000 and 110,000 t per year is given in Germany and the EU, respectively. So far, this gap is filled almost completely by increased mining of rock phosphates. Alternatively, a general application of microbial phytase to all diets would largely fill this gap. Until the ban, MBM contributed to 57% of the supplementation of P that was needed for pigs and poultry. The ban of MBM makes large amounts of P irreversibly disappearing from the food chain. (3.) Energy from slaughter offal and cadavers can be utilized in different technologies, in the course of which the efficiency of energy utilisation depends on the technology applied. It is efficient in the cement work or rotation furnace if heat is the main energy required. In contrast, the energetic efficiency of fermentation is low. (4.) Incineration or co-incineration of MBM and other by-products causes pollution gas emissions amounting to about 1.4 kg CO2 and 0.2 kg NOx per kg. The CO2 production as such is hardly disadvantageous, because heat and electrical energy can be generated by the combustion process. The prevention of dangerous gaseous emissions from MBM burning is current standard in the incineration plants in Germany and does not affect the environment inadmissibly. (5.) The effects of the MBM ban on the price for compound feed is not very significant. Obviously, substitution possibilities between different feed ingredients helped to exchange MBM without large price distortions. However, with each kg MBM not used in pig and poultry feeding economic losses of about 0.14 [symbol: see text] have to considered. In conclusion, the by far highest proportion of raw materials for MBM comes as by-products from the slaughter process. Coming this way, and assuring that further treatment is safe from the hygienic point of view, MBM and animal fat can be regarded as valuable sources of amino acids, minerals and energy in feeding pigs and poultry. Using them as feedstuffs could considerably contribute to the goal of keeping limited nutrients, phosphorus in particular, within the nutrient cycle and dealing responsible with limited resources.

Amino Acids↗

Progress toward measles elimination in Germany.

While the former East Germany (FEG) achieved a reduction of measles incidence to <1 case per 100,000 population before reunification in 1990, the former West Germany (FWG) experienced significant measles morbidity. In 2001, according to statutory surveillance data, the incidence of measles was still higher in FWG than in FEG (8.7 vs. 0.7 cases/100,000 population). This article describes the development of the vaccination strategies in FEG and FWG, vaccination coverage, results of seroprevalence studies, measles surveillance in Germany, the epidemiology of a recent outbreak, and the role of laboratory diagnosis for measles control in Germany. Recent establishment of comprehensive nationwide surveillance and prevention programs to attain higher vaccine coverage have led to a decrease in measles incidence. However, further improvement of age-appropriate vaccine coverage and closure of immunity gaps in school-age children are necessary to eliminate measles in Germany.

Adolescent↗

Vaccination policy against smallpox, 1835-1914: a comparison of England with Prussia and Imperial Germany.

There are three identifiable phases in comparing vaccination policy in England, Prussia and Imperial Germany. (1) Prior to the 1870's the tradition of medical police in Prussia resulted in the vaccination of the population being treated as a State responsibility earlier than in England and provided an appropriate administrative framework. The administrative pressure that could be exerted persuaded the Prussian authorities that legislation to make vaccination compulsory was unnecessary. In contrast, England and Wales lacked both the tradition and administrative structures of a medical police. Legislation (1840, 1853) for free and universal infant vaccination was followed by radical ideological and administrative innovation. (2) From 1875 to 1889 both countries provided free and compulsory vaccination for all. In England this was limited to infants; in Germany including Prussia, it included the re-vaccination of children. (3) After 1889 England and Germany began to diverge more sharply. In England vaccination rates fell and after 1898 conscientious objectors were excused from having to have their children vaccinated. Germany retained compulsory vaccination and rates in the two countries increasingly diverged. England came to rely on the local public health administration for the surveillance and containment of smallpox, including selective vaccination of contacts. Despite these differences smallpox mortality dropped sharply in both countries, although in Germany somewhat earlier. The English reliance on surveillance and containment prefigures that of the WHO in the eradication of smallpox in the Third World. It suggests that the emphasis on the importance of high levels of mass vaccination in the German literature should perhaps be revised.

Germany↗

Penicillin-resistant Streptococcus pneumoniae in Germany: genetic relationship to clones from other European countries.

Penicillin-resistant Streptococcus pneumoniae strains isolated in different parts of Germany between 1982 and 1992 were compared with penicillin-resistant isolates, mainly of serogroups 6, 9, 14, 19 and 23, from other European countries. The main clones were recognised by their serotypes, antibiotic resistance patterns and penicillin-binding protein properties, and this typing was confirmed by multi-locus enzyme electrophoresis for a sample of 43 selected isolates. Eleven of the 14 resistant German isolates could be assigned to five genotypes isolated also in other countries. These included representatives of two distinct serotype 23F lineages predominant in Spain and France; a cluster of three serotype 6B isolates identical to clones in Spain, France, Finland and Hungary; and a serotype 9V clone of a type prevalent in Spain and now also in France. Serotype 19A clones of the type found in Hungary were not collected in Germany. The data suggest that two 23F lineages, represented by seven isolates from different locations, have become disseminated in Germany. Several resistant types found in the former West Germany resembled those found elsewhere in Western Europe whereas those from East Germany were distinct or, in one case, resembled a clone from Hungary. These data may reflect pre-unification travel patterns.

Bacterial Proteins↗

A new approach to determine the total airborne N input into the soil/plant system using 15N isotope dilution (ITNI): results for agricultural areas in Central Germany.

The atmospheric deposition of nitrogen (N) in the environment is of great concern due to its impact on natural ecosystems including affecting vegetation, reducing biodiversity, increasing tree growth in forests, and the eutrophication of aquatic systems. Taking into account the average annual N emission into the atmosphere in Germany of about 2 million t N (ammonia/ammonium, NOx), and assuming homogeneous distribution throughout Germany, an average N deposition of 45 kg/ha x year can be calculated. Such high atmospheric N deposition could be confirmed by N balances from long-term field experiments in Central Germany (e.g., the Static Fertilization Experiment in Bad Lauchstdt). By contrast, estimates by standard methods indicate a deposition of only about 30 kg N/ha x year. This is because the standard methods are using wet-only or bulk collectors, which fail to take into account gaseous deposition and the direct uptake of atmospheric N by aerial plant parts. Therefore, a new system was developed using 15N isotope dilution methodology to measure the actual total atmospheric N input into a soil/plant system (Integrated Total Nitrogen Input, ITNI). A soil/plant system is labeled with [15N]ammonium-[15N]nitrate and the total input of airborne N is calculated from the dilution of this tracer by N from the atmosphere. An average annual deposition of 64 +/- 11 kg/ha x year from 1994-2000 was measured with the ITNI system at the Bad Lauchstdt research farm in the dry belt of Central Germany. Measurements in 1999/2000 at three other sites in Central Germany produced deposition rates of about 60 kg/ha x year. These data clearly show that the total atmospheric N deposition into the soil/plant system determined by the newly developed ITNI system significantly exceeds that obtained from standard wet-only and bulk collectors. The higher atmospheric N depositions found closely match those postulated from the N balances of long-term agricultural field experiments.

Chemistry Techniques, Analytical↗

Lower prevalence of asthma and atopy in Turkish children living in Germany.

Ethnic origin has been reported to affect the prevalence of atopic diseases in several studies in different parts of the world. However, little is known about the prevalence of asthma and atopy in immigrants living in Europe. The objective of this study was to evaluate the prevalence of asthma and atopy in Turkish children living in Germany and to investigate the role of ethnic origin on the development of asthma and atopy in this population. In a cross-sectional survey the prevalence of physician-diagnosed asthma, atopy, skin-prick tests and bronchial hyperresponsiveness (BHR) to cold dry air challenge was assessed in 7,445 school children aged 9-11 yrs, living in Munich, south Germany. Questionnaires were distributed to the parents for self-completion and children underwent skin prick tests and cold air hyperventilation challenge. The Turkish children showed a significantly lower prevalence of asthma (5.3 versus 9.4%, p<0.05) than their German peers. Furthermore, atopy, as assessed by skin prick tests (24.7 versus 36.7%, p<0.001) and BHR (3.9 versus 7.7%, p<0.001), was less common in Turkish children. In multivariate regression models controlling for potential explanatory factors, Turkish origin still showed a significantly lower risk of developing asthma, atopic sensitization and BHR. The prevalence of childhood asthma was therefore shown to be lower in Turkish children living in Germany than in Turkey. These findings suggest that the lower prevalence of asthma and allergy in Turkish children living in Germany might be attributable to a selection bias affecting the parents of these children, as healthy individuals may have decided to come to Germany for work.

Age Distribution↗

Changes in social inequality with respect to health-related living conditions of 6-year-old children in East Germany after re-unification.

BACKGROUND: Since Germany re-unified in 1990, substantial social and economic changes have happened in East Germany, the former socialist German Democratic Republic (GDR). The aim of this study was to investigate the influence of these socio-economic changes in East Germany on the association between social status, measured by parental educational level, and health-related living conditions of children during the ten-year period after re-unification. METHODS: In total, 25,864 6-year-old school beginner children (51.2% male and 48.8% female) participated in cross-sectional studies which have been repeated every year from 1991 to 2000 in East Germany. Parental educational level as a social indicator was the independent variable. Dependent variables included not employed parents, small living space and health-related living conditions (e. g. damp housing, single oven heating and living at busy road). The relationships were described by odds ratios using logistic regression. RESULTS: A large overall effect of parental educational level on health-related living conditions was observed. The time trends showed that the situation regarding small living space, damp housing conditions and single oven heating improved from 1991 to 2000, while regarding not employed parents (1996-2000) and living at busy road (1991-2000) did not, but even deteriorated. 6-year old children with low parental educational level, who lived at the time of re-unification, were often under damp housing conditions and with single oven heating at homes. Nevertheless, this social inequality has almost vanished ten years later. In contrast, we found an increasing gap between low and high parental educational level with respect to the proportion of parents who were not employed (22%: 4% gain), or lived under cramped housing conditions (22%: 37% reduction), or close to a busy road (7% gain: 2% reduction). CONCLUSION: The social inequalities which already existed under the socialist system in East Germany persisted in the system of social market economy between 1991 and 2000. 6-year-old children from families with the lowest social status were living under the worst domestic conditions (e. g. living at busy road, having damp housing conditions, single oven heating and small living space) and for some conditions (e. g. living at busy road and having small living space) the gap betweenlow and high social status was even bigger in 2000 than in 1991.

Child↗

Consumption, knowledge, and handling of raw meat: a representative cross-sectional survey in Germany, March 2001.

Outbreaks of gastroenteritis have been repeatedly associated with the consumption of raw meat and raw meat products. To assess the potential of this problem in Germany, frequency of consumption and knowledge about and handling of raw meat during food preparation in the German population was estimated. We conducted a population-based nationwide cross-sectional survey in private households in March 2001 by random telephone numbers. Consenting German-speaking persons were randomly chosen among household members for standardized interviews. Proportions were standardized by age, sex, and region (eastern and western Germany). A total of 510 people were interviewed (response 45.1%), including 62.3% women and 31.8% considered at high risk (children younger than 10 years old, elderly more than 65 years old, and chronically ill persons). The mean age was 45.7 years. Of those who ate raw ground meat at least once a week, 17.8% lived in eastern Germany and 5.1% in western Germany, (chi-square test, P < 0.001). Teewurst was eaten by 50.8% of all respondents and 53.8% of respondents in the high-risk group. That salami or Teewurst were raw meat products was known to 58.1 and 36.3% of the respondents, respectively. Respondents reported not washing their hands (46.6%) or cleaning their cutting boards with soap (48.1%) after preparing raw meat. A total of 10.3% of the respondents had diarrhea during the last 3 months. Although knowledge is poor, consumption of raw meat products is widespread in Germany, even among high-risk persons. More information is necessary on which products contain raw meat, the potential risk of diarrhea after raw meat products are consumed, and appropriate handling of raw meat products.

Adolescent↗

[Prevalence of the ticks Dermacentor marginatus (Sulzer, 1776) and Dermacentor reticulatus (Fabricius, 1794) and their importance as vectors of diseases in Germany (author's transl)].

From a systematical study of German ticks resulted the occurrence of two tick species of the genus Dermacentor. D. marginatus is found to be widely spread in Southern Germany. Adults of the tick feed mainly on sheep. D. reticulatus is first described from Germany where the tick occurs endemic in a limited forest area on red deer. The two tick species are known from neighbouring countries of Germany in transmitting virus, rickettsiae, bacteriae and protozoa but are not yet well studied in Germany. Geiographical distribution and seasonal occurrence of D. marginatus indicates the role of the tick in the epidemiology of Q fever in Germany.

Animals↗

Is Germany a model for managers?

Most American managers have a hard time making sense of Germany. The country has a fraction of the resources and less than one-third the population of the United States. Labor costs are substantially higher, paid vacations are at least three times as long, and strong unions are deeply involved at all levels of business, from the local plant to the corporate boardroom. Yet German companies manage to produce internationally competitive products in key manufacturing sectors, making Germany the greatest competitive threat to the United States after Japan. The seemingly paradoxical nature of the German economy typically evokes one of two diametrically opposed responses. The first is to celebrate the German economy as a "model" worth emulating--indeed, as the answer to declining U.S. competitiveness. The alternative, more skeptical response is to question Germany's staying power in a new, more competitive global economy. According to Kirsten Wever and Christopher Allen, the problem with both points of view is that they miss the forest for the trees. Observers are so preoccupied with praising--or blaming--individual components of the German economy that they fail to see the dynamic logic that ties these components together into a coherent system. In their review of recent research on the German business system, Wever and Allen argue that managers can learn an important lesson from Germany. In the global economy, competition isn't just between companies but between entire socioeconomic systems. Germany's ability to design a cohesive economic and social system that adapts continuously to changing requirements goes a long way toward explaining that country's competitive success.

Administrative Personnel↗

Improving return-to-work strategies in the United States disability programs, with analysis of program practices in Germany and Sweden.

The General Accounting Office (GAO) has made recommendations for improving the disability programs by citing practices that have been successful in Germany, Sweden, and the private sector. This issue is important in the United States because the number of disability beneficiaries is growing rapidly, program costs are increasing proportionately, and few disability recipients are leaving the disability rolls to resume work activity. GAO points out that the estimated lifetime savings for removing an additional 1 percent of the disabled beneficiaries from the rolls of the Disability Insurance (DI) and the Supplemental Security Income (SSI) programs each year will ultimately reach $3.0 billion. GAO cites three specific practices as showing the most promise for returning the disabled to work. They are (1) intervening as soon as possible after a disabling event to promote and facilitate return to work, (2) identifying and providing necessary return-to-work assistance and managing cases to achieve return-to-work goals, and (3) structuring cash and health benefits to encourage people with disabilities to return to work. This article examines these suggestions to improve the rate of rehabilitation of disabled workers using research by experts on return-to-work practices in Germany, Sweden, and the United States. Experts caution that any consideration of borrowing practices from other countries needs to take into account the unique economic, social, and political elements in each country. Although other countries appear to be very successful in their rehabilitation programs, practices that are successful in one country may not necessarily work well in another. Countries have different definitions of disability and payment structures. The existence of temporary and partial awards in Germany and Sweden may ensure a number of easily rehabilitated individuals, while the U.S. vocational rehabilitation (VR) agencies have been mandated to focus on only the most severely disabled individuals. Public expenditures for vocational rehabilitation, work for the disabled, and disability benefits are much higher as a percentage of gross domestic product in Germany and Sweden than they are in the United States. Compared with the United States, Germany spent twice as much for VR, and Sweden spent 2.6 times more. Impediments to GAO's suggestions include divergent goals of the Social Security program and VR agencies, lack of availability of VR services, the timing of VR referral (which is significantly later than the onset of the disability), and little incentive for return to work built into the payment structure. The Work Incentives Improvement Act of 1999 is currently being considered by a Congressional conference committee. The bill would establish a Ticket to Work and Self-Sufficiency program and would require or authorize the Social Security Administration to demonstrate and evaluate different ways of encouraging return to work. In designing these demonstrations, early intervention after a potentially disabling illness or injury is an approach that merits serious attention.

Persons with Disabilities↗

Input pathways and river load of pesticides in Germany--a national scale modeling assessment.

A model has been developed which estimates the magnitude and the spatial distribution of pesticide losses from diffuse sources (surface run-off, tile drains and spraydrift) into surface waters for the entire area of Germany. The cumulative annual losses of 42 active ingredients applied to 11 field crops, orchards and vineyards are calculated for river basins in Germany based on grid maps with a resolution of 1 x 1 km2. The model validation showed a sufficient degree of accuracy of the model results compared to measured pesticide loads in 13 small catchments. According to the model results the pesticide input from diffuse sources into surface waters amounted to 13.8 t in 1994 aggregated for the entire area of Germany. Input via surface runoff contributed 9.1 t while tile drainage was 1.4 t and spraydrift 3.4 t respectively. Alongside the model calculations empirical data of the pesticide load of rivers in Germany are presented. A comparison of the measured river loads with the modeled inputs from non-point sources leads to the conclusion that in most regions of Germany the largest portion of the load is due to the input from farm effluents.

Agriculture↗

[Performance of in vitro fertilization in Germany].

In Germany the application of assisted reproductive techniques (ART) is regulated by federal legislation. Compared with the international situation the "German Embryo Protection Law" is very "restrictive" and various methods of ART are prohibited, e.g. oocyte/embryo donation, embryo cryopreservation and Preimplantation Genetic Diagnosis (PGD). Furthermore, in Germany only 1 to 3 fertilized oocytes may be cultured to embryo. All these embryos then have to be transferred into the uterus of a particular patient. Additional fertilized oocytes can only be cryopreserved in a pronuclear state. The success rate of ART has increased significantly over the past few years owing to the introduction of blastocyst cultures and the selection of 1 to 2 good quality blastocysts for embryo transfer. Furthermore, the transfer of only 1 to 2 blastocysts effectively reduces the risk of high rank multiple pregnancies. In Germany, however, the selection of only a few good quality blastocysts for transfer is prohibited by law. New laboratory techniques, e.g. pronuclear scoring and polar body biopsy screening for aneuploidy are in accordance with German law. The application of these methods provides a selection of "good quality oocytes" and seems to increase the overall success rate. Further studies are required, however. The success rate, quality and cost effectiveness of ART in Germany appears compromised when compared with many other countries. What is more, in contrast to the international situation research and development in ART in Germany has been decreasing constantly over the past few years, due to the inappropriate regulations of the German health care system and the insufficient support given to university-based centers.

Blastocyst↗

[Quality control in medical education and continuing medical education in allergology in Germany].

Quality control in education and training in allergology comprises activities at the different levels of the curriculum of medical schools, residency programs and postgraduate education. Unfortunately, until now allergology in Germany has not yet been regularly embedded in the medical curriculum of all medical schools. Therefore, the German Society for Allergology and Clinical Immunology (DGAI) has demanded for years that chairs and departments of allergology be introduced at every Medical Faculty in Germany. The new Medical Licensure Rules (Approbationsordnung) offer the possibility to select allergology, amongst others, as an obligatory subject in the medical state examination. Furthermore, allergological topics can now be introduced into the newly established interdisciplinary fields (Querschnittsbereiche). At the level of residency training, doctors who want to become allergists have to undergo a special curriculum in the field of allergology, formerly called additional specialisation in allergology (Zusatzbezeichnung) after having finished their board examination in an organ-related specialty subject. Following a decision of the German "Arztetag" in May 2003, this 24-months curriculum has unfortunately been reduced to 18 months. 12 months of this 18 months requirement may be fulfilled during a residency programme in either dermatovenerology, otolaryngology, internal medicine, pulmology and/or paediatrics. Compared to previous years, this results in a drastic deterioration of allergy training in Germany. The DGAI has decided to take up the fight for its improvement in both a quantitative and qualitative respect. The crucial issue is to develop quality criteria for persons as well as institutions eligible as training centres in allergology. As regards post-graduate education, the German Academy of Allergology and Environmental Medicine (Deutsche Akademie für Allergie und Umweltmedizin, DAAU) has introduced a system of certified continuing medical education (CME), which has been widely accepted in Germany. CME credit points are awarded in co-operation with the regional physicians' chambers ("Landesärztekammer"). Quality control in allergology has to be re-enforced and improved at all levels of medical curricula, training programmes and post-graduate education in order to achieve sustainable improvements in patient care for the large number of people in Germany suffering from allergies.

Allergy and Immunology↗

Risk factor patterns for coronary heart disease in China, Japan and Germany.

The risk factor patterns for coronary heart disease in China, Japan and Germany were studied. 6,025 Germans, 7,580 Japanese and 2,047 Chinese aged 30-59 were investigated following the protocol of the Göttingen Risk, Incidence, and Prevalence Study carried out in West Germany in 1982. It is concluded that in China, the risk factor intervention focuses mainly on smoking and hypertension; smoking also remains the most important risk factor in Japan; while in Germany the major targets are obesity and hyperlipidemia. However, about 38% of the participants from West Germany showed 3 or more risk factors accumulated per person. Thus the multifactorial risk factor reduction might be necessary in Germany.

Adult↗

Comparative studies on pheno- and genotypic properties of Staphylococcus aureus isolated from bovine subclinical mastitis in central Java in Indonesia and Hesse in Germany.

In the present study, 35 Staphylococcal strain isolated from milk samples of 16 cows from eight farms of three different geographic locations in Central Java, Indonesia, and from milk samples of 19 cows from 19 farms of different geographic locations in Hesse, Germany, were compared pheno- and genotypically. On the basis of cultural and biochemical properties as well as by amplification of the 23S rRNA specific to Staphylococcus aureus, all isolates could be identified as S. aureus. In addition, all S. aureus isolates harboured the genes clfA and coa encoding staphylococcal clumping factor and coagulase, and the gene segments encoding the immunoglobulin G binding region and the X-region of protein A gene spa. By PCR amplification, the genes seb, seg, seh, and sei was observed for the S. aureus cultures isolated in Central Java, Indonesia and the genes sec, sed, seg, seh, sei, sej and tst for the S. aureus cultures isolated in Hesse, Germany. None of the S. aureus of both origins harboured the genes sea, see, eta and etb. All isolates were additionally positive for the genes nuc, fnbA, hla, and set1. The gene hlb was found for 6 cultures from Central Java, Indonesia and 16 cultures from Hesse, Germany. However, the gene fnbB and the gene segments cnaA and cnaB were not present among the strains isolated in Central Java, Indonesia and rare among the strains isolated in Hesse, Germany. It was of interest that most of the S. aureus isolated in Central Java, Indonesia harboured the gene cap5 and most of the strains isolated in Hesse, Germany the gene cap8. The phenotypic and genotypic results of the present study might help to understand the distribution of prevalent S. aureus clones among bovine mastitis isolates of both countries and might help to control S. aureus infections in dairy herds.

Animals↗

Managing mental health service provision in the decentralized, multi-layered health and social care system of Germany.

BACKGROUND: The effective coordination of mental health service provision is a requirement for successfully reforming mental health care from a hospital-focused system towards a more decentralized, community-oriented one. Implementing such coordination is particularly challenging in a decentralized, multi-layered health and social care system such as exists in Germany. AIM OF THE STUDY: (i) To investigate the coordination and planning of mental health service provision performed at and between the local, Länder and federal political levels in Germany; (ii) to outline the disparities in coordination and planning of mental health service provision that exist between the different political levels and locate key-authorities; (iii) to determine whether a decentralized, multi-layered health and social system such as Germany's allows for adequate coordination. METHOD: (i) Analysis of mental health legislation and policy documents; (ii) guided interviews with officers and consultants of the government units responsible for mental health affairs of the 16 Länder and the federal Ministry of Health and Social Security; (iii) submission of results to the interviewed experts for verification. RESULTS: Multi-professional boards and posts for coordinating and planning mental health services are widely implemented on local state and federal level in Germany. Most of them operate without being required by legislation. The sickness and pension funds are represented in less than half of the boards on state level. Boards on local and on state level are mainly concerned with coordinating social mental health care and have little influence on medical mental health care. Mental health policy documents exist federally and in most Länder. All but one of the mental health legislations of the Länder (present in 12 out of the 16 Länder) also considers regulations concerning coordinating and planning mental heath services. The key-authorities for mental-health policy, legislation and service implementation is with the 16 Länder. The federal government however plays an important frame setting role. Actual service provision is a local responsibility. DISCUSSION: Since the beginning of mental health reforms 25 years ago and in particular in recent years, structures for the coordination and planning of mental health service provision have been established countrywide at local, Länder and federal levels. However, there are hardly any structures that connect the Länder and local levels and act as a source of independent quality assurance. The coordination boards at the Länder level include almost all the parties involved in mental health care, with the exception of sickness and pension funds that are, for the most part, absent. Thus the coordination boards are mainly restricted to governing social services in mental health care. Despite this, the countrywide establishment of diverse boards for the structured coordination of mental health service provision can be regarded in itself as a success, although little is known of the processes and impact of this framework. There are, however, indications that coordination is still restricted to the traditional interfaces and dividing lines of the mental health care system, which they seem unable to overcome. IMPLICATION FOR HEALTH POLICIES: The reform of mental health service provision towards a more community-orientated approach requires sophisticated coordination. The countrywide establishment of structures for the coordination and planning of mental health service provision has been largely possible in Germany. It does, however, require further analysis, since coordination beyond the traditional boundaries seems unlikely. Therefore, incentives are needed in order to encourage "adequate coordination" as well as integration with other parts of the mental health care system.

Community Mental Health Services↗

Surveillance of Lyme borreliosis in Germany, 2002 and 2003.

Lyme borreliosis is a potentially serious infection common in Germany, but little data about its incidence, distribution, and clinical manifestations are available. Lyme borreliosis is not a notifiable disease in Germany, but six of Germany's 16 states - Berlin, Brandenburg, Mecklenburg-Vorpommern, Sachsen, Sachsen-Anhalt and Thüringen, have enhanced notification systems, which do include Lyme borreliosis. The efforts made in these states to monitor confirmed cases through notification are therefore an important contribution to understanding the epidemiology of Lyme borreliosis in Germany. This report summarises the analysis of Lyme borreliosis cases submitted to the Robert Koch-Institut during 2002-2003. The average incidence of Lyme borreliosis of the six East German states was 17.8 cases per 100,000 population in 2002 and increased by 31% to 23.3 cases in 2003, respectively. Patient ages were bimodally distributed, with incidence peaks among children aged 5- 9 and elderly patients, aged 60- 64 in 2002, and 65- 69 in 2003. For both years, 55% of patients were female. Around 86% of notified cases occurred from May to October. Erythema migrans affected 2697 patients (89.3%) in 2002 and 3442 (86.7%) in 2003. For a vector-borne disease, like Lyme borreliosis, the risk of infection depends on the degree and duration of contact between humans and ticks harbouring Borrelia burgdorferi. As infectious ticks probably occur throughout Germany, it is likely that the situation in the remaining 10 German states is similar to that of the states in this study.

Adolescent↗