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1. In Germany health protection against injuries at work is distinctly separated from the general health care of the population. 2. Health protection at work includes: recognition, prevention, treatment and rehabilitation connected with occupational diseases as well as prevention of accidents at work. The total cost of this system including accident indemnities is covered by the employer. 3. The system of health care and safety at work within the enterprise comprises a coordinated activity of the physician inspector and a representative of the enterprise and the owner. 4. In big enterprises there is another system operating parallel to the one mentioned above: this system provide comprehensive health care. The costs are covered by contributions both on the paid of the employers and the employees.
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In the Federal Republic of Germany no large Q fever epidemics (more than 200 cases) have been encountered within the last 20 years; however, Q fever was prevalent throughout that period on a constant level (between 27 and 100 officially reported cases per year). Besides classical pneumonic Q fever, chronic forms associated with endocarditis, myocarditis and hepatitis were recently diagnosed for the first time in the Federal Republic of Germany. The disease Q fever in humans is often misdiagnosed as common cold or influenza, and more attention should be paid to this entity by the medical profession. Within ten years there has been a sharp increase of Q fever infections in livestock and pets as proved by seroepidemiologic investigations. Preliminary results of a seroepidemiological study indicate a parallel increase of seropositives in the human population, but further investigations on larger numbers of sera are required for statistic confirmation. There are reasons to believe that, in contrast to general opinion, in the Federal Republic of Germany C. burnetii is involved now in infertility in cattle, and besides being a zoonosis Q fever must be considered as a potentially important infectious disease of cattle causing economic losses in this country. Further investigations on this matter are required.
In the Federal Republic of Germany, as in most other countries, the dose limit is 50 mSv per year for occupationally exposed persons, as recommended by the International Commission on Radiological Protection (ICRP). A reduction in the annual dose limit was recently considered in connection with a discussion of a higher estimation of radiation risk. In the recent amendment of the German Radiological Protection Ordinance, however, the dose limit of 50 mSv per year was retained and additionally a new occupational lifetime dose limit of 400 mSv was introduced. The possible consequences of the 400 mSv dose limit will be discussed on the basis of the previous results of dose monitoring in the Federal Republic of Germany.
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In the Federal Republic of Germany, the debate on public health is dominated by the question as to the cost and the financing of good health care. Indeed, expenditure planning has now become the main area of planning in the public health sector. By contrast, the plans to improve health standards and to intensify health protection as well as to improve the quality and efficacy of health provision are somewhat neglected. This is probably due, in the main, to the strong position held by the providers of medicines and medical services and thus, by the same token, to the weak position of the consumers. Although there exists a well known set of statistics and indicators to describe the state of public health in this country, there is an almost complete absence of any attempt to evaluate them for planning purposes. The scope of intervening in the sphere of health care is thus left to a large number of protagonists characterized by completely heterogeneous interests. What we lack is a system of target-oriented plans and concrete measures. In the field of providing health care and combating disease, the only available systematic planning concerns the provision of in-patient and out-patient medical services: there is no planning for the quality of such facilities or for the range and quality of psychosocial and nursing services. As regards health-expenditure planning--which has made the biggest advances--the participants enjoy a great deal of independence: the volume of spending and increases in expenditure are thus the outcome of a process of negotiation. Under the current planning philosophy, consensual decision-making enjoys a high status.
In the Federal Republic of Germany 67 experts were questioned concerning the diffusion of 10 procedures in minimally invasive surgery (MIS). Most of the ten procedures have potential economic advantages and benefits for the patient. Informants state that more randomized controlled trials are needed. Extra-corporeal shock wave lithotripsy, percutaneous transluminal coronary balloon angioplasty, sclerosing of sites of upper gastrointestinal bleeding (including esophageal varices), and arthroscopic meniscectomy are well-established; laparoscopic cholecystectomy made a breakthrough in 1990. The diffusion process of the others is promising. Main obstacles to further diffusion are high investment and maintenance costs, long delivery time for special instruments, lack of systematic training in MIS, performance regulations, and conservatism. Investigations into total costs are necessary. Since the present financing of hospital services through per diem payment is detrimental to the diffusion of MIS, lump-sum payments could remove barriers to diffusion. New methods of interlinking hospital and out-patient care should be tested.
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Until recently, in the Federal Republic of Germany there has been a lack of epidemiological data on asbestos-related tumors. Only the numbers of occupational diseases accepted for compensation by the German industrial injuries insurance institutes (Berufsgenossenschaften) can be stated. These show, for 1979, 94 cases of asbestosis, 21 cases of asbestosis associated with lung cancer, and 34 cases of mesothelioma. Since 1972 employees exposed to asbestos dust have been included in a central register by the industrial injuries insurance institutes and are medically examined periodically. By December 31, 1979, 28,476 persons were registered. Of those, 6,582 were still being followed medically, although they were no longer working with asbestos dust exposure. In January 1, 1977, a prospective epidemiological study was started with these people who were formerly exposed to asbestos dust. Up to December 31, 1980, altogether 2,944 people were enrolled in the study. Besides several other enrollment criteria, the individual's permission was required to evaluate his personal data. Of the people enrolled, 85 had died by December 31, 1980. Even if five questionable cases of lung cancer are excluded (n = 80), the observed rates of about 43% tumours of all sites, with 15% lung cancer and 6% mesothelioma, seem to be comparable to the international epidemiological mortality pattern.
In the Federal Republic of Germany, the morbidity curve of meningococcal infections from 1966-1984 exhibited two maxima in 1970 and 1979 representing morbidity values of 2.9 and 2.3 per 100,000 of the population, and a small peak in 1974. The average morbidity of the 19 years was 2.1/10(5), the lowest morbidity 1.3/10(5) (1983/84). Meningitis occurred on an epidemic scale in 1970 in Bremen, in 1971 in Schleswig-Holstein and 1971-1977 in the Saarland. Most cases were notified during the first four four-week periods of the year, but in two years (1967, 1969), the late-summer peak exceeded the peak of winter/spring. 17.3% of the cases occurred in infants, 51.7% in the first five years of life. Morbidity was highest during the second quarter of the first year. The sex ratio (m:f) of the infections was 1.6:1, but in the aged, morbidity was about the same in both sexes (0.9:1). The case-fatality ratio varied between 7.1% (1977) and 12.1% (1971, 1982) and averaged at 9.7%. It was highest in the aged (37.1%) and second-highest in infants (18.7%). Differences of lethality due to sex could not be demonstrated. Of 1.685 meningococcal strains isolated from CSF and/or blood, 7.3% were of serogroup A, 74.4% of group B, 15% of group C, 1.5% of group Y and 1.1% of group W135. The proportion of group B infections was highest in infants, of group A infections in children (5-10 years), of group C infections in older children and adolescents (10-20 years). The sensitivity of N. meningitidis to sulfadiazine varied with serogroup and year of isolation. Since 1977, practically all group A strains, but only 13% of group B and 9% of group C strains proved to be resistant. Practically all strains were fully sensitive to rifampicin and minocycline; results of trials with spiramycin were not in support of the use of this compound as a chemoprophylactic agent.
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In Switzerland and in the Federal Republic of Germany the reporting of HIV infections is based on an anonymous mandatory reporting system for laboratories. In Switzerland, physicians have to complete a questionnaire on the patient's clinical status and risk behaviour. To make a rough estimate of the prevalence of HIV infections in the general population at low risk, data on blood donations are used in both countries. In Switzerland, additional data with information on positive and negative test results have been obtained since 1985 from anonymous test sites. In both countries, the data do not show evidence of an increasing incidence of HIV infection. The number of positive test results reported by the laboratories and physicians remains stable, and the rates of HIV-positive blood donations are declining. In the Federal Republic of Germany, homo-/bisexual men play the most important role in the epidemic, whilst in Switzerland, injecting drug users contribute most to the burden of HIV infection, and the proportion of persons probably heterosexually infected is increasing steadily. Possible selection biases need to be further discussed.