Eurosurveillance

ECDC

Prioritisation of infectious diseases in public health - call for comments

 Rediger
  Published: 25.06.09 Updated: 25.06.2009 14:27:14

G.Krause1, the working group on prioritisation at the Robert Koch Institute (RKI)2

  1. Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
  2. The members of the working group are listed at the end of the article

The following article is a secondary publication. Citation style for this article: Krause G, the working group on prioritisation at the Robert Koch Institute (RKI). Prioritisation of infectious diseases in public health - call for comments. Euro Surveill. 2008;13(40):pii=18996. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=18996

In order to allocate rationally resources for research and surveillance of infectious diseases at the level of the German public health institute (RKI), we prioritised pathogens by public health criteria. After screening the relevant literature we developed a standardised methodology including a three-tiered scoring system for selected pathogens. The pathogens were rated in four categories containing a total of 12 criteria: burden of disease including incidence, severity, mortality; epidemiologic dynamic including outbreak potential, trend, emerging potential; information need including evidence on risk factors/groups, validity of epidemiologic information, evidence for pathogenesis; international duties and public attention; health gain opportunity including preventability, treatability. For each criterion a numerical score of +1, 0 or -1 was given and each criterion received a weight by which the numerical score of each criterion was to be multiplied.  The total weighted scores ranged from +22.7 (influenza) to - 64.4 (cholera) with the median being -22.9 (rubella). Relevant changes were observed between weighted and unweighted scores. The chosen approach proved to be feasible and the result plausible. However, in order to further improve the methodology we invite experts to give feedback on the methodology via a structured web-based questionnaire at www.rki.de/EN > Prevention of infection > Infectious Disease Surveillance > Pathogen prioritization. Results of this survey will be included in a modification of the methodology.

Background
One of the challenges of public health is that infectious disease control covers a wide range of pathogens requiring diverse methods for prevention and control. Furthermore, infectious diseases vary greatly in occurrence, severity and other factors that make it difficult to compare the public health importance of the underlying pathogens. Resources for research, surveillance and other public health activities are limited; it is therefore of major importance to allocate rationally these resources by using public health criteria. The agendas of institutions in the field of public health and infectious diseases, however, are fragmented and experts are increasingly specialised, making it difficult to find institutions or individuals who would be able to prioritise a broad range of infectious diseases without being biased by individual professional focus on one hand or lack of specific pathogen-related knowledge on the other.
In the past decade a number of efforts have been made to prioritise systematically infectious diseases by public health criteria resulting in different outcomes depending on the objectives and methodology used [1-5]. But even prioritisation schemes with similar objectives have applied different sets of criteria as illustrated in Table 1.

Table 1. Comparison of the evaluation criteria of different schemes for prioritisation of infectious diseases (the prioritisation by Réseau National de Santé Publique, 1995, France, is not included as it contained categorisation principles rather than criteria) between 1995 and 2008

Reference

Rushdy & O’Mahony 1998 (3)

Weinberg et al 1999 (20)

Doherty 2000 (1)

Horby et al 2001 (2)

Institute de Veille Sanitaire (InVS) 2001 (5)

World Health Organisation 2003 (4)

Krause et al. 2008 (6)

Country

United Kingdom

European Union

Canada

United Kingdom

France

South East Europe

Germany

Group of criteria

Specific name of criteria (as used in respective publications)

International aspects and public concern

- public concern

- public health laboratory service (PHLS)-added value

- international surveillance programmes

- international consideration

- risk perception

- potential to drive public health policy

- other sector interest

-public concern

- not applied -

- not applied -

- international duties and public attention

Occurrence

- not applied -

- not applied -

- incidence

- not applied -

- epidemiology

- not applied -

- incidence

Epidemiologic dynamic

- potential threat

- not applied -

- potential spread

- changing patterns

- potential threat

- not applied -

-potential threat

-long term effects on communicable diseases

- outbreak potential

- trend

- emerging potential

Burden of disease

- burden of ill health

- not applied -

- severity

- burden of ill health

- not applied -

-disease impact

-present burden of ill health

- severity

- mortality

Health gain opportunity

- health gain opportunity

- not applied -

- preventability

- health gain opportunity

- prevention and control measures

-low incidence only maintained by public health activities

- health gain opportunity

- necessity for immediate public health response

- preventability

- treatability

Socioeconomic aspects

- social/economic impact

- collective economic impact

- socioeconomic burden

- social/economic impact

- not applied -

-social/economic impact

- not applied -

Information need

- not applied -

- not applied -

- not applied -

- not applied -

- not applied -

- not applied -

- evidence for risk factors/groups

- validity of epidemiologic information

- evidence for pathogenesis

Other

- not applied -

- not applied -

- not applied -

- not applied -

- veterinary public health

- not applied -

- not applied -

In 2004 the department for infectious disease epidemiology of the Robert Koch Institute (RKI), the national public health institute in the portfolio of the German federal ministry of health, initiated a prioritisation exercise to guide the research and surveillance strategies of the department [6]. Initial findings were presented at three international scientific conferences in 2006 and 2007 [7-9].

After this a publication in a nationwide non-scientific journal [10] elicited considerable and unexpected interest from the general public and the scientific community. Therefore, as part of updating and improving the current prioritisation methodology, we would like to present this methodology also to the broader international public health community outside the RKI and Germany to collect suggestions for improvement. In the following we describe and evaluate the methodology of the prioritisation previously conducted by the RKI to provide the background information necessary for comment on our approach. We cordially invite comments on the proposed methodology via a web-based questionnaire accessible at http://www.rki.de/EN > Prevention of infection > Infectious Disease Surveillance > Pathogen prioritization.

Methodology
While preparing our exercise we analysed prioritisation efforts over the past decade by searching the literature in Medline using the search terms prioritisation OR priority AND (surveillance OR infectious diseases OR public health) and based on presentations from the EAN (EPIET Alumni Network) workshop on "New Tools for early Warning" that took place in Lyon on 6 and 7 February 2004, [1-5,18,19]. A flow chart of our methodology is presented in Figure 1.

Figure 1. Work flow prioritisation, Robert Koch Institute, 2008

Figure 1. Work flow prioritisation, Robert Koch Institute, 2008

 

 

 

 

 

 

 

 

 

 

 

 

A list of pathogens was compiled based on one or more of the following criteria: notifiable according to German law [11], reportable within the European Union according to European regulations [12], listed as chapters in selected established manuals and textbooks on infectious diseases [13-15], causative agent in outbreaks reported to RKI in the past 10 years, agent with potential for deliberate release [16]. In the following we list the pathogens but also refer to the related diseases in humans.

Every pathogen was rated according to the 12 criteria listed in Table 2. For each criterion a numerical score of +1, 0 or -1 was given as defined in Table 2. The score of +1 represented high and a score of -1 low importance with respect to a criterion. A score of 0 referred to pathogens with average importance or pathogens, for which lack of knowledge or opinion of the participants in the working group did not allow a decision for one of the other two scores.

Table 2. Criteria and definition of the respective scores for the prioritisation of pathogens, Robert Koch Institute, 2008

Criteria

Values

 

-1

0

1

Burden of disease

 

 

 

Incidence

<1/100.000

1/100.000-20/100.000

>20/100.000

Severity

hospitalisation is very rare, work loss less than 2 days, no persisting handicaps

hospitalisation is rare, work loss of more than 5 days is rare, very rarely persisting handicaps

hospitalisation is frequent, work loss of more than 5 days is frequent, persisting handicaps do occur

Mortality*

<50 deaths/year in Germany

between 50 und 500 deaths /year in Germany

more than 500 deaths /year in Germany

Epidemiologic dynamic

 

 

 

Outbreak potential

outbreaks are very rare

outbreaks with 5 or more cases are rare

outbreaks with 5 or more cases are frequent

Trend

diminishing incidence rates

stable incidence rates

increasing incidence rates

Emerging potential

disease already endemic or very unlikely to be introduced to Germany

disease has the potential to be introduced to Germany sporadically

disease is likely to emerge in Germany in a relevant way

Information need

 

 

 

Evidence for risk factors /groups

risk factors and risk groups are identified based on scientific evidence

risk factors and risk groups are basically known but scientific evidence is missing

risk factors and risk groups are not known

Validity of epidemiologic information

epidemiologic situation is well known and scientifically valid

epidemiologic information exists but is scientifically not very valid

epidemiologic information is insufficient

International duties and public attention

no international duties or political agenda, minor public attention

no international duties but informal political expectations, moderate public attention

international duties or explicit political agendas, high public attention

Evidence for pathogenesis

information on pathogenesis and transmission routes is  available and well supported by scientific evidence

information on pathogenesis and transmission routes is  basically available but not well supported by scientific evidence

information on pathogenesis and transmission routes is hardly available

Health gain opportunity

 

 

Preventability

there are hardly any possibilities for prevention or there is no need for prevention

concepts for prevention are established but there is need for further research to improve its effectiveness

strong need for further research on preventive measures because need for prevention is clear but concepts for prevention are missing

Treatability

medical treatment is rarely necessary or effective treatments are available to positively influence the burden of disease or the prognosis

medical treatment is frequently indicated but medical  treatments only have a limited  influence on the burden of disease or the prognosis

medical treatment is desirable but currently there is no treatment available that  positively influences the burden of disease or the prognosis

Proposed alternative to mortality

 

 

Case fatality rate*

<0,01%

0,01- 1%

> 1%

Each criterion received a weight by which the numerical score of each criterion was to be multiplied. Hence for each pathogen a sum of the unweighted and a sum of the weighted scores was generated. The weight of each criterion was determined before and independently of the categorisation for each pathogen: all participants were asked to put the 12 criteria in a sequential order with 12 being the most important and one being the least important criterion. An average was computed for each criterion, defining its weight. The total weighted score was defined as the sum of the weighted scores of all 12 categories per pathogen. These were finally normalised to the spectrum of the unweighted total scores to allow comparisons. We demonstrate the effect of weighting by presenting detailed data on the highest, lowest and median ranking pathogen as well as for the two pathogens with adjacent ranks to the median rank.

Results
The overview of prioritisation exercises in Table 3 shows that objectives, methodological approaches and especially the level of standardisation differed considerably in these efforts. Partly due to different objectives of the prioritisation, also the number and type of criteria varied. Categories used by most groups are incidence, burden of disease and opportunity for health gain [1-5], which are included in our exercise.

Table 3. Comparison of general features of different schemes for prioritisation of infectious diseases between 1995 and 2008

Reference

Anonymous 1995 (19)

Rushdy & O’Mahony 1998 (3)

Weinberg et al 1999 (20)

Doherty 2000 (1)

Horby et al 2001 (2)

Institute de Veille Sanitaire (InVS) 2001 (5)

World Health Organisation 2003 (4)

Krause et al. 2008

Year

1995

1997

1997

1998

1999

2000-2001

2002

2005

Country

France

United Kingdom

European Union

Canada

United Kingdom

France

South East Europe

Germany

Organisation

Réseau National de Santé Publique (RNSP)

Public health laboratory service (PHLS) Overview of Communicable Diseases Committee

Charter group of European Commission (EC)

Canadian Advisory Committee on Epidemiology

Public health laboratory service (PHLS) Overview of Communicable Diseases Committee

 Institute de Veille Sanitaire (InVS)

Dubrovnik Pledge /World Health Organisation

Robert Koch Institute

Prioritisation objective

select diseases for surveillance

programme initiatives in infectious disease control

select diseases for surveillance  

select diseases for surveillance

programme initiatives in infectious disease control

prevention of non-food-borne zoonotic diseases

select diseases for surveillance

epidemiological research and surveillance

Number of diseases

84

33 (+8 generic disease groups)

26

43

58 (+11 generic disease groups)

37

53

85

Number of criteria

3 principles

5 criteria

9 criteria

10 criteria

5 criteria

> 5 criteria

8 criteria

12 criteria

Scoring system

No

5-tiered

5-tiered

3-, 4-, and 6-tiered

5-tiered

not quantifiable

5-tiered

3-tiered

Score-specific definition

no

no

no

yes

no

no

no

yes

Weighting applied

no

no

no

implicitly

no

no

no

systematically

Methodology of collecting opinion

Delphi

survey

Delphi

Delphi

survey

working group

Delphi

Delphi

Number of participants

over 50

194

14

6

518

10

not published

11

Type of participants

interministerial and regional experts

experts in communicable disease control and public health laboratory service (PHLS)

heads of national institutions with responsibilities for communicable diseases surveillance

provincial epidemiologists

different health care professionals

interministerial and regional experts

participants of World Health Organisation workshop (not published)

epidemiologists at national public health institute (RKI)

The working group on prioritisation consisted of eleven senior epidemiologists and infectious disease specialists at the department for infectious disease epidemiology at RKI. They categorised a list of 85 pathogens shown in Table 4.

Table 4. List of pathogens selected for prioritisation, Robert Koch Institute, 2008

Adenovirus / Аденовирус

Escherichia  coli, shigella toxin producing (STEC/HUS) / Escherichia coli, вырабатывающая токсин (гемолитическо-уремический синдром)

Leishmaniaspp.

Salmonellatyphi

Babesia microti

Echinococcus granulosus

Leptospira interrogans

Shigella spp.

Bacillus anthracis

Echinococcus multilocularis

Listeria monocytogenes

Staphylococcus aureus, methicillin resistant (MRSA) / Золотистый стафилококк, устойчивыйк метициллину

Bartonella spp.

Ehrlichia chaffeensis

Measles virus / Вирус кори

Staphylococcus aureus, toxigenic/ Золотистый стафилококк, токсикогенный

Bordetella pertussis

Entamoeba histolytica

Microsporum spp.

Streptococcusspp. other than Str.pneumoniae /  Streptococcus spp. за исключением Str. pneumoniae

Borrelia burgdorferi

Epstein-Barr virus / Вирус Эпштейна-Барра

Molluscipoxvirus / Вирус контагиозного моллюска

Streptococcus pneumoniae

Brucella abortus

Francisella tularensis

Mumpsvirus / Вирус эпидемического паротита

Toxoplasma gondii

Bovine Spongioform Encephalitis (BSE)/ variant Creutzfeldt Jakob Disease (vCJD) / Губчатая энцефалопатия коров (BSE)/ вариант болезни Крейтцфельда-Якоба

Giardia lamblia

Mycobacterium Leprae

Treponema pallidum

Campylobacter jejuni

Haemophilus influenzae

Mycobacterium tuberculosis

Trichinella spiralis

Central European tick-borne encephalitis virus / Вирус клещевого энцефалита Центральной Европы

Hanta virus / Вирус Ханта

Mycobacterium, other (non-tuberculous) / Mycobacterium, микобактерии другие (не туберкулезные)

Trichomonias vaginalis

Chlamydophila pneumoniae

Helicobacter pylori

Mycoplasmaspp.

Varicella virus / Вирус ветряной оспы

Chlamydophila psittaci

Hepatitis A virus / Вирус гепатита А

Neisseria gonorrhoeae

Variolavirus / Вирус оспы натуральной

Chlamydia trachomatis

Hepatitis B virus / Вирус гепатита В

Neisseria meningitidis

Vibrio cholerae

Clostridium botulinum

HepatitisCvirus / Вирус гепатита С

Norovirus / Норовирус

Viruses, others causing hemorrhagic fevers / Другие вирусы, вызывающие геморрагические лихорадки

Clostridium tetani

Hepatitis D virus / Вирусгепатита D

Parvovirus B 19 / Парвовирус В 19

WestNilevirus / Вирус Западного Нила

Corynebacterium diphtheria

Hepatitis E virus / ВирусгепатитаЕ

Plasmodiumspp.

Yellow fever virus / Вирус желтой лихорадки

Coxiella burnetii

Herpes simplex virus (HSV) / Вирус простого герпеса (ВПГ)

Polio virus / Вирус полиомиелита

Yersinia enterocolitica

Cryptosporidium parvum

Human immunodeficiency virus (HIV) / Вирус иммунодефицита человека (ВИЧ)

Rabiesvirus / Вирус бешенства

Yersinia pestis

Cyclospora cayetanensis

Human papilloma virus (HPV) / Вирус папилломы человека (ВПЧ)

Rota virus / Ротавирус

Yersinia pseudotuberculosis

Cytomegalovirus / Цитомегаловирус

Human T-cell lymphotrophic virus (HTLV) / Вирус Т-клеточной лимфомы человека

Rubellavirus / Вирус краснухи

 

Dengue virus / Вирус Денге

Influenza virus / Вирус гриппа

Salmonella spp. (non typhi non paratyphi)

 

Escherischia coli, enteropathogenic (non STEC/HUS) / Escherischia coli, энтеропатогенная (кроме STEC/HUS)

Legionella pneumophila

Salmonella paratyphi

 

The distribution of the normalised ranks is presented in Figure 2 and detailed scores for selected diseases are shown in Table 5. The total weighted scores ranged from +22.7 (influenza) to - 64.4 (cholera) with the median being -22.9 (rubella). The spectrum found in the total unweighted scores contained 12 possible ranks ranging from +2 to -9. Table 5 demonstrates the differences obtained from weighting for some selected pathogens.

Figure 2. Distribution of pathogens by total weighted and unweighted scores during prioritisation, Robert Koch Institute, 2008

Figure 2. Distribution of pathogens by total weighted and unweighted scores during prioritisation, Robert Koch Institute, 2008

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 5. Prioritisation scores for five selected pathogens out of 85, Robert Koch Institute, 2008

 

 

Crude weighted scores / Грубые взвешенные оценки

 

 

Maximum / Максимальная величина

 

Median / Средняя величина

 

Minimum / Минимальная величина

Disease / Заболевание

Weight / Весовой коэффициент 

Influenza / Грипп

Rotavirus / Ротавирусная инфекция

Rubella / Краснуха

Cyclosporiasis / Циклоспороз

Cholera / Холера

Burden of disease / Бремяболезни

 

 

 

 

 

Incidence / Заболеваемость

10.7

10.7

10.7

0

-10.7

-10.7

Severity / Тяжесть заболевания

10.3

0

-10.3

-10.3

-10.3

0

Mortality / Смертность

8.4

8.4

0

-8.4

-8.4

-8.4

Epidemiologic dynamic / Эпидемиологическаядинамика

 

 

 

 

 

Outbreak potential / Возможность вспышки

10.1

10.1

10.1

10.1

0

-10.1

Epidemiologic trend / Эпидемиологическая тенденция

7.7

0

0

0

0

-7.7

Emergingpotential / Потенциал возвращения инфекции

5.4

-5.4

-5.4

-5.4

0

0

Informationneed / Потребность в информации

 

 

 

 

 

 

Evidence for risk factors/groups / Данные по факторам/группам риска

5.5

-5.5

-5.5

-5.5

5.5

-5.5

Validityofepidemiologicinformation / Достоверность эпидемиологической информации

5.4

-5.4

-5.4

0

5.4

-5.4

Politicalagendas, publicawareness/ Международные обязательства и общественное внимание

5.2

5.2

0

-5.2

-5.2

0

Evidence for pathogenesis / Признаки патогенеза

3.4

-3.4

-3.4

-3.4

0

-3.4

Healthgainopportunity / Возможность улучшения здоровья

 

 

 

 

 

Preventability / Возможность профилактики

8.0

8

-8

0

0

-8

Treatability /  Возможность лечения

5.2

0

-5.2

5.2

0

-5.2

Totalweightedscore (crude) / Итоговая взвешенная оценка (грубая)

22.7

 -22.8

-22.9

-23.7

-64.4

Totalun-weightedscore / Итоговая невзвешенная оценка

1

-5

-4

-2

-9

Totalweightedscore (normalisedtoascalefrom +2 to -9) / Итоговая взвешенная оценка (нормализованная к шкале от +2  до  -9)

2

-4

-4

-4

-9

Discussion and conclusions
The described methodology builds on the experiences of similar efforts [1-5,18, 19] and attempts to increase the level of standardisation and transparency in prioritising pathogens based on public health criteria. In comparison to the cited prioritisation efforts, our approach may appear overly standardised. We believe, however, this ensures transparency and reproducibility, which are important, especially as prioritisation may easily affect funding and policy issues. Furthermore, our methodology allows for adaptations if certain conditions change e.g. if a vaccine becomes available or if the incidence changes significantly.
The result of the prioritisation at RKI shows a multi-modal distribution with the majority of scores below 0 indicating that, with a given definition of scores and a list of diseases to prioritise, participants tended to opt more frequently for lower scores. Therefore, we propose to replace the criterion of mortality by case fatality, as presented in Table 2, because mortality is implicitly dependant on incidence, whereas case fatality is another criterion for burden of disease complementing the criterion of severity. Among the selected diseases presented, the proposed exchange would somewhat lower the score for influenza but it does not seem to result in a relevant change of ranking.

A five-tiered scoring system as used in the overview of communicable diseases or in the Dubrovnik pledge could allow for a more differentiated scoring than the three-tiered system we used  [2-4]. However, the challenge to generate clear definitions for each score increases with the number of scores. For many diseases and criteria information may not be available in the detail needed to permit such a differentiated approach.

The examples in Table 5 demonstrate that some diseases that were far apart in the unweighted scaling moved close together after weighting had been applied. This makes it obvious that weighting is important and that it may result in changes in both directions. There is reason to believe that the objectiveness of the procedure is increased if weighting is done independently of, and prior to, scoring. This is a way to avoid individual preferences of participants biasing the process. The advantage of quantitatively determining the weight for each individual criterion is that other institutions may choose to apply different weights to adapt the ranking to their respective mission. This increases the flexibility of the system and allows it to be used for different applications. For example the Eurostat task force on human health issues related to food safety has recently adopted a number of our criteria and also our concept of weighting in an attempt to identify the top 20 diseases from the inventory of food safety related diseases in Europe. (Ana Martinez, Eurostat, personal communication)

Call for comments
For an upcoming update of our prioritisation methodology we plan to include the views from experts from various fields and institutions outside the RKI.

While suggesting that a structured prioritisation approach similar to the one presented here is useful, there are still a number of questions that we plan to re-assess before going through such a procedure again:

  • Does the list contain all relevant pathogens?
  • Do the 12 criteria cover the relevant characteristics for prioritisation and are they not redundant or strongly dependant on each other? If other categories are missing, would the available information suffice to allow scoring based on defined scores?
  • For which categories would a five-tiered scaling be a major improvement and if so would it be feasible to generate clear definitions for each scale?
  • Are the existing definitions for the three scores for each criterion clear and plausible? Can they be applied? Are they valid to detect differences?
  • Is the weighting of the criteria plausible?
  • How large should the group of participating experts be and how should it be composed?

We invite suggestions, feedback and answers to the questions above through a structured web-based questionnaire available from http://www.rki.de/EN > Prevention of infection > Infectious Disease Surveillance > Pathogen prioritization. This may initiate a fruitful discussion in the scientific community and provide some guidance on how to improve our prioritisation scheme and maybe that of other institutions. Ultimately, we hope this will in return contribute to rational allocation of attention and resources in the control and prevention of infectious diseases.

Acknowledgements
Special thanks to Jessica Bielecke, Denise Neugebauer, Andreas Gilsdorf for editorial support and Daniel Faensen, Göran Kirchner and Andreas Tille for the installation of the web based questionnaire.

Members of the working group on prioritization at the RKI:
K Alpers, J Benzler, V Bremer, H Claus, W Haas, O Hamouda, G Laude, G Rasch, I Schöneberg, K Stark, all department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany, and A Ammon, European Centre for Disease Prevention and Control, Stockholm, Sweden.

References

  1. Doherty J-A. Establishing priorities for national communicable disease surveillance. Can J Infect Dis. 2000;11(1):21-4.
  2. Horby P, Rushdy A, Graham C, O'Mahony M, PHLS Overview of Communicable Diseases Committee. PHLS overview of communicable diseases 1999. Commun Dis Public Health. 2001;4(1):8-17.
  3. Rushdy A, O'Mahony M. PHLS overview of communicable diseases 1997: results of a priority setting exercise. Commun Dis Rep CDR Suppl. 1998;8(5):S1-12.
  4. World Health Organization (WHO). The Dubrovnik pledge on surveillance and prioritization of infectious diseases.  Report on a WHO Meeting, Bucharest, Romania, 21–23 November 2002. Copenhagen: WHO; 2003. Available from: http://www.euro.who.int/document/e78888.pdf
  5. Institut de Veille Sanitaire (InVS). Definition of priorities in the area of non-food-borne zoonoses 2000-2001. [In French]. St. Maurice: InVS; 2002. Available from: http://www.invs.sante.fr/publications/2002/def_priorite_zoonoses/index.html
  6. Krause G, Working Group on Prioritization at Robert Koch Institute. How can infectious diseases be prioritized in public health? A standardized prioritization scheme for discussion. EMBO Rep. 2008;9 Suppl 1:S22-7.
  7. Krause G, Alpers K, Benzler J, Bremer V, Claus H, Haas W, et al. Prioritising infectious diseases in Germany [Poster]; International Meeting on Emerging Diseases and Surveillance, 23.-25.02.2007 Vienna, Austria.
  8. Krause G, Alpers K, Benzler J, Bremer V, Claus H, Haas W, et al. Standardised Delphi Method for Prioritising Foodborne and Zoonotic Diseases in Germany [Poster]; Priority Setting of Foodborne and Zoonotic Pathogens; 19.-21.07.2006 Berlin, Germany.
  9. Krause G. Prioritization of Infectious Diseases by Public Health Criteria, 8th EMBO/EMBL Joint Conference on Science and Society; 2.-3.11.2007 Heidelberg, Germany.
  10. Mayer K-M. Parade der Keime - Deutschlands Seuchenexperten reihen erstmal Infektionserreger nach deren Gefährlichkeit. Focus 2007 Mar 5;44.
  11. Gesetz zur Neuordnung seuchenrechtlicher Vorschriften - (Seuchenrechtsneuordnungsgesetz - SeuchRNeuG vom 20. Juli 2000). Bundesgesetzblatt 2000;33(Teil I - G5702):1045-77.
  12. Decision No 2119/98/EC of the European Parliament and of the Council. European Commission Communicable Disease Network Committee; 1998.
  13. Heymann D. Control of Communicable Diseases Manual. Washington: American Public Health Association; 2004.
  14. Murray P, Baron EJ, Pfaller MA, Tenover FC, Yolken RH. Manual of Clinical Microbiology. Washington: American Society for Microbiology; 1999.
  15. Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. Washington: American Society for Microbiology; 2005.
  16. Tegnell A, Van Loock F, Baka A, Wallyn S, Hendriks J, Werner A, et al. Development of a matrix to evaluate the threat of biological agents used for bioterrorism. Cell Mol Life Sci. 2006;63(19-20):2223-8.
  17. Jones J, Hunter D. Qualitative research: Consensus methods for medical and health services research. BMJ. 1995 5;311(7001):376-80.
  18. Reseau National De Sante Publique (Saint-Maurice). Revision de la politique de Surveillance des Maladies infectieuses.  1995 Oct 24.
  19. Weinberg J, Grimaud O, Newton L, On behalf of the Charter Group. Establishing priorities for European collaboration in communicable disease surveillance. Eur J Public Health. 1999;9(3):236-40

 Print