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Inhalt
1Zusammenfassung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
2Einleitung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1Ziel der Influenzasurveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2Geschichte und Struktur der Influenza?berwachung inDeutschland . . . . 16
2.3Einbindung in internationale Netzwerke . . . . . . . . . . . . . . . . . . . . 17
3Begriffs- und methodische Erl?uterungen . . . . . . . . . . . . . . . . . . . 19
4Datenquellen und erhobene Daten . . . . . . . . . . . . . . . . . . . . . . . . 23
4.1Syndromische ?berwachung akuter respiratorischerb Erkrankungen . . . 23
4.2Virologische Surveillance der AGI . . . . . . . . . . . . . . . . . . . . . . . . . 26
4.3Daten der kooperierenden Landeslabore . . . . . . . . . . . . . . . . . . . 29
4.4Von den Gesundheits?mtern ?bermittelte Daten nach IfSG . . . . 29
5Influenza-?berwachung in der Saison 2018/19 im Vergleich mit fr?heren Saisons . . 33
5.1Ergebnisse der Surveillance (?bermittelte F?lle gem?? IfSG) . . . 33
5.2Ergebnisse der Sentinel-Surveillance . . . . . . . . . . . . . . . . . . . . . . . 36
5.3Influenza-bedingte Todesf?lle (Exzess-Sch?tzungen) . . . . . . . . . 46
5.4Internationale Situation in der Saison 2018/19 . . . . . . . . . . . . . . 48
6Virologische Analysen in der Influenzasaison 2018/19 . . . . . . . . 49
6.1Influenzavirusnachweise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6.2Isolierte Viren . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
6.3Antigene Charakterisierung der Influenzaviren . . . . . . . . . . . . . . . 50
6.4Molekulare Charakterisierung der Influenzaviren . . . . . . . . . . . . . 58
6.5Untersuchungen zur antiviralen Resistenz . . . . . . . . . . . . . . . . . . 70
6.6Untersuchungen zu weiteren respiratorischen Viren . . . . . . . . . . 73
7Weitere Ergebnisse zur Influenzasaison 2018/19 aus syndromischen Surveillancesystemen des RKI . . 79
7.1GrippeWeb – syndromische Surveillance akuter Atemwegserkrankungen auf Bev?lkerungsebene . . . . 79
7.2SEEDARE – Ergebnisse zur fallbasierten Auswertung von akuten respiratorischen Erkrankungen
in der prim?r?rztlichen, ambulanten Versorgung . . . . . . . . . . . . . . . . . . 85
7.3ICOSARI – ICD-10-Code basierte Krankenhaussurveillance schwerer akuter respiratorischer Infektionen . . 92
7.4Mortalit?tssurveillance in Berlin und Hessen . . . . . . . . . . . . . . . . 99
8Influenzaimpfung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
8.1Zusammensetzung des Impfstoffs . . . . . . . . . . . . . . . . . . . . . . . . 103
8.2Impfempfehlung f?r saisonale Influenza in der Saison 2018/19 .......103
8.3Wirksamkeit der Impfung gegen saisonale Influenza (Impfeffektivit?t) . . . 104
9Influenza als Zoonose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
9.1Avi?re Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
9.2Porcine Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
9.3Fazit zu Influenza an der Schnittstelle zwischen Mensch und Tier . . 113
10Literaturhinweise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
12Anhang . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
12.1Abbildungsverzeichnis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
12.2Tabellenverzeichnis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Impressum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
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Executive Summary
The information on the epidemiology of influen-
za in Germany for the 2018/19 season is main-
ly based on the analysis and assessment of data
collected by the Robert Koch Institute’s (RKI) va-
rious surveillance systems for the monitoring of
acute respiratory infections (ARI), particularly in-
fluenza, in Germany. The national sentinel system
of the Working Group on Influenza (AGI) with its
syndromic surveillance of acute respiratory disea-
ses and the virological surveillance of respiratory
pathogens continues to be a central instrument
in the overall concept of influenza surveillance in
Germany. The virological data of the AGI on influ-
enza are supplemented by results of six state labo-
ratories cooperating with AGI in Baden-W?rttem-
berg, Bavaria, Mecklenburg-Western Pomerania,
Saxony, Saxony-Anhalt and Thuringia. Mecklen-
burg-Western Pomerania contributed syndromic
data from sentinel practices of the state’s own sur-
veillance. The National Influenza Center (NIC)
conducted additional virological analyses of circu-
lating influenza viruses and the consultant labora-
tory for RSV, parainfluenza viruses and metapneu-
moviruses added characterisation results for RSV.
Mandatory reports of laboratory confirmed cases
of influenza were obtained from the German local
health authorities who submitted notifications via
state health authorities to the RKI. These were also
included in the report, as were the results from the
web-based participatory surveillance system Grip-
peWeb where 14,000 participants are registered.
Finally we present results from the electronic mo-
dule of the AGI (SEEDARE), the hospital surveil-
lance system for severe acute respiratory infec-
tions (ICOSARI) and timely mortality data from
the federal states Berlin and Hesse.
This season we identified the first influenza
viruses, namely A(H3N2) viruses, within the AGI
sentinel in the 44th calendar week (CW) 2018. In
the 2nd CW 2019 the proportion of influenza-po-
sitive samples (positivity rate) rose to 18 %. Thus,
in the 2018/19 season the flu epidemic began in
the 2nd CW and it ended in the 14th CW 2019
in early April. The activity of acute respiratory di-
seases, measured by the so called practice index,
reached values of high ARI activity from CW 6 to
8 2019. However, the values of the practice index
during the peak of the flu epidemic in the 8th and
9th CW 2019 remained below the values of the
last two seasons.
We estimate that a total of approximately
3.8 million influenza-attributable medically atten-
ded acute respiratory illnesses (iMAARI) occurred
(95 % confidence interval (CI), 3.0 – 4.6 million).
including approximately 2 million iMAARI by in-
fluenza A(H1N1)pdm09 and around 1.8 million
iMAARI through influenza A(H3N2). Especially
at the beginning of the flu epidemic, there was an
overlap with MAARI, especially in infants, who
were caused by RSV. Around one million rMAARI
in the 2018/19 season were attributed to this pa-
thogen. Influenza-associated (physician certified)
incapacities for work (or the need for bed rest in
patients who do not need a sick leave note) were
estimated at 2.3 million (95 % CI 2.1 – 2.5 milli-
on). The estimated number of influenza-related
hospitalizations from primary care practices was
18,000 (95 % CI 16,000-20,000).
Compared with previous seasons, the estima-
te for iMAARI is therefore significantly lower than
in the extraordinarily severe flu epidemic in the
2017/18 season and the severe seasons 2012/13
and 2014/15. The estimate for influenza-attribu-
table hospital admissions is also lower than the
estimates for 2016/17 and 2017/18, roughly com-
parable to the values for the 2015/16 season.
As in the previous season, the number of
laboratory-confirmed hospitalised influenza cases
reported through the mandatory reporting system
exceeded the AGI estimate, likely because the lat-
ter is restricted to hospital admissions from GP or
pediatric practice and does not include – for ex-
ample – direct admissions through the emergency
care system.
For the 2018/19 season, no estimate of excess-
mortality could be made, as the necessary data of
the Federal Statistical Office are published with a
time delay. However, the estimate for the 2017/18
season (still lacking in the last annual report)
has been supplemented: approximately 25,000
influenza-related deaths exemplify – together with
other parameters – the extraordinary severity of
the flu epidemic 2017/18.
According to the virological sentinel surveil-
lance conducted by the NIC influenza A(H1N1)
pdm09 and A(H3N2) viruses co-circulated during
the flu epidemic from the start. Since the end of
February influenza A(H3N2) viruses dominated.
In total, 51 % influenza A(H1N1)pdm09 and 49 %
influenza A(H3N2) viruses were detected. Influ-
enza B viruses circulated only sporadically during
the 2018/19 season, and were not identified in the
sentinel. The influenza A(H1N1)pdm09 viruses
reacted well with post-infection ferret antiserum
raised against the respective vaccine viruses and
with the vaccine strains recommended for the up-
coming 2019/20 season. For the A(H3N2) viruses
the antigenic analysis showed no good agreement
with the vaccine strains. The NIC also conducted
molecular analyses of influenza-positive samples
in the context of the investigation and manage-
ment of influenza outbreaks conducted by local
health authorities where also severe cases had
occurred. In addition, samples were analysed that
were sent to the NIC coming from other patients
with a severe or fatal course. Finally, the NIC had
also tested approximately 36 % of the influenza vi-
ruses for resistance against antivirals. Except for
one influenza A(H1N1)pdm09 virus, where resis-
tance may have occurred under therapy, all viruses
tested were susceptible to the neuraminidase inhi-
bitors oseltamivir, zanamivir and peramivir. The
influenza viruses examined were also sensitive to
the antiviral drug baloxavir marboxil, which has
not yet been licensed in the EU. The RSV charac-
terized by the consultant laboratory belonged with
more than 60 % to group B (as was the case in
the 2017/18 season), while in the 2016/17 season
RSV group A viruses dominated with about 60 %.
The analysis of the GrippeWeb data shows
that the ILI rates in the 2018/19 influenza season
were similar to an averaged course based on data
from the years 2011 to 2018. In this report we
show also the proportion of patients with ARI or
ILI symptoms who visit a physician because of the
symptoms.
The distribution of the ICD-10 diagnostic
codes for ARI in ambulatory care is shown in the
more detailed analysis of the SEEDARE data. The
number of consultations in which certain ICD-10
codes for upper respiratory tract infections, in-
fluenza or lower respiratory tract infections have
been used, showed a clear seasonal pattern. In the
2018/19 season, it was noticeable that especially
infants were seriously ill and a higher proportion
as usual was hospitalized. Using the case-based
anonymous information from the SEEDARE modu-
le, further respiratory syndromes can also be spe-
cifically analysed, such as illnesses that have been
coded as community-acquired pneumonia.
For the assessment of progression to seve-
re disease, valuable information was obtained in
the context of the ICD-10 code based syndromic
hospital surveillance for severe acute respiratory
infections (ICOSARI) in the 2018/19 season. The
number of hospitalized SARI patients was signifi-
cantly lower than in the 2017/18 season, but high
SARI case numbers in the 0- to 4-year age group
were again documented.
In the timely analysis of excess mortality du-
ring the season, the report presents the estimates
for the states Berlin and Hesse. Here too, the esti-
mates were lower than in the more severe seasons
2016/17 and 2017/18.
The World Health Organization’s (WHO) an-
nual recommendations on influenza vaccines, the
recommendations of the German Standing Com-
mittee on Vaccination (STIKO), and the assess-
ment of the influenza vaccine effectiveness for the
2018/19 season are all presented in the chapter
?Influenza Vaccination?. For the 2019/20 season,
the WHO recommended a different composition
of the influenza vaccine for the influenza A(H1N1)
pdm09 and the A(H3N2) components in compari-
son to the Northern Hemisphere 2018/19 season:
” an A/Brisbane/02/2018 (H1N1)pdm09-like vi-
rus (new);
” an A/Kansas/14/2017 (H3N2)-like virus (new);
” a B/Colorado/06/2017-like virus (Victoria li-
neage) unchanged; and
” a B/Phuket/3073/2013-like virus (Yamagata li-
neage) unchanged.
As in the previous seasons, the effectiveness of
influenza vaccination in the 2018/19 season was
assessed by analysing the virological surveillance
data of the AGI. The overall effectiveness of seaso-
nal influenza vaccine against laboratory-confir-
med influenza disease was low, however, effects
differed by subtype: effectiveness against influen-
za A(H1N1)pdm09 disease was high, while no ef-
fectiveness was shown against laboratory confir-
med influenza A(H3N2) disease.
Lastly, the chapter on zoonotic influenza descri-
bes the situation on avian and porcine influenza
in their respective animal species, as well as in hu-
mans. As in previous years, no human case with
zoonotic influenza virus infection was reported in
Germany. However, also in the 2018/19 season,
human infections with avian and porcine influen-
za viruses occured worldwide. They were mostly
attributed to exposure to infected animals. There
was also no evidence of sustained human-to-hu-
man transmission with these zoonotic influenza
viruses. As long as the influenza viruses circulate
in livestock, sporadic human infections may con-
tinue to occur.