Bavarian Health Research Articles

Urine Screening for Narcotics under Court-Imposed Abstinence Requirements: Comparative Validity of Forensic-Toxicological Analyses with Involvement of Public Health Services

Assessment of the comparative validity between qualitative and quantitative analyses of urine screenings for defined narcotics residues under court-imposed abstinence restrictions. Following the introduction of a valid marker system which, based on the application of a defined sugar substance and its detection in the urine of person under probation in 2006, urine samples were assayed in administrative cooperation by a Bavarian public health office for probationary services for evidence of narcotics. The urine samples were sent to an external laboratory in order to carry out forensic toxicological analyses for defined narcotics. The qualitative and quantitative laboratory results were reported back to the public health department so that a digital-based data set of a total of 380 persons with more than 27,000 individual analyses from a total of 14 consecutive calendar years could be established and retrospectively evaluated in an anonymised form. The overall prevalences of findings positive for narcotics were 2.7% (n=366 of 13,531) for the qualitative and 2.6% (n=348 of 13,525) for the subsequent quantitative result categorisations, with cannabis and opiates being detected most frequently in both test methods. Using the kappa coefficient as a quantitative measure for the comparative validity of both test methods, the test results showed the highest agreement (1.000) for buprenorphine and lowest agreement for PCP (0.880). No age- and gender-specific stratifications could be recorded for a total of ten different narcotic substances; substance-specific case numbers differed among the analyses. Based on the strong to very strong correspondences between qualitative and quantitative narcotics analysis results, it could be assumed that both analysis methods accurately recorded violations of abstinence requirements and were to be classified as sufficiently substantiating for judicial decisions under the Narcotics Act (Betäubungsmittelgesetz, BtMG). According to these results, the content of urine screenings for narcotics controlling abstinence should be discussed.

Mapping Regional Differences in Infection Rates for the Coronavirus (COVID-19): Results of a Bayesian Approach to Administrative Districts of Bavaria

Since the beginning of the COVID-19 pandemic, thematic maps showing the spread of the disease have been of great public interest. From the perspective of risk communication, those maps can be problematic, since random variation or extreme values may occur and cover up the actual regional patterns. One potential solution is applying spatial smoothing methods. The aim of this study was to show changes in incidence ratios over time in Bavarian districts using spatially smoothed maps. Data on SARS-CoV-2 were provided by the Bavarian Health and Food Safety Authority on 29.10.2021 and 17.02.2022. The demographic data per district are derived from the Statistical Report of the Bavarian State Office for Statistics for 2019. Four age groups per sex (<18, 18-29, 30-64,>64 years) divided into 16 time periods (01/28/2020 to 12/31/2021) were included. Maps show standardized incidence ratios (SIR) spatially smoothed by Bayesian hierarchical modelling. The SIR varied remarkably between districts. Variations occurred for each time period, showing changing regional patterns over time. Smoothed health maps are suitable for showing trends in incidence ratios over time for COVID-19 in Bavaria and offer the advantage over traditional maps in giving more realistic estimates by including neighborhood relationships. The methodological approach can be seen as a first step to explain the regional heterogeneity in the pandemic, and to support improved risk communication.

Practices and Attitudes of Bavarian Stakeholders Regarding the Secondary Use of Health Data for Research Purposes During the COVID-19 Pandemic: Qualitative Interview Study.

BackgroundThe COVID-19 pandemic is a threat to global health and requires collaborative health research efforts across organizations and countries to address it. Although routinely collected digital health data are a valuable source of information for researchers, benefiting from these data requires accessing and sharing the data. Health care organizations focusing on individual risk minimization threaten to undermine COVID-19 research efforts, and it has been argued that there is an ethical obligation to use the European Union’s General Data Protection Regulation (GDPR) scientific research exemption during the COVID-19 pandemic to support collaborative health research.ObjectiveThis study aims to explore the practices and attitudes of stakeholders in the German federal state of Bavaria regarding the secondary use of health data for research purposes during the COVID-19 pandemic, with a specific focus on the GDPR scientific research exemption.MethodsIndividual semistructured qualitative interviews were conducted between December 2020 and January 2021 with a purposive sample of 17 stakeholders from 3 different groups in Bavaria: researchers involved in COVID-19 research (n=5, 29%), data protection officers (n=6, 35%), and research ethics committee representatives (n=6, 35%). The transcripts were analyzed using conventional content analysis.ResultsParticipants identified systemic challenges in conducting collaborative secondary-use health data research in Bavaria; secondary health data research generally only happens when patient consent has been obtained, or the data have been fully anonymized. The GDPR research exemption has not played a significant role during the pandemic and is currently seldom and restrictively used. Participants identified 3 key groups of barriers that led to difficulties: the wider ecosystem at many Bavarian health care organizations, legal uncertainty that leads to risk-adverse approaches, and ethical positions that patient consent ought to be obtained whenever possible to respect patient autonomy. To improve health data research in Bavaria and across Germany, participants wanted greater legal certainty regarding the use of pseudonymized data for research purposes without the patient’s consent.ConclusionsThe current balance between enabling the positive goals of health data research and avoiding associated data protection risks is heavily skewed toward avoiding risks; so much so that it makes reaching the goals of health data research extremely difficult. This is important, as it is widely recognized that there is an ethical imperative to use health data to improve care. The current approach also creates a problematic conflict with the ambitions of Germany, and the federal state of Bavaria, to be a leader in artificial intelligence. A recent development in the field of German public administration known as norm screening (Normenscreening) could potentially provide a systematic approach to minimize legal barriers. This approach would likely be beneficial to other countries.

Nowcasting the COVID-19 pandemic in Bavaria.

To assess the current dynamics of an epidemic, it is central to collect information on the daily number of newly diseased cases. This is especially important in real‐time surveillance, where the aim is to gain situational awareness, for example, if cases are currently increasing or decreasing. Reporting delays between disease onset and case reporting hamper our ability to understand the dynamics of an epidemic close to now when looking at the number of daily reported cases only. Nowcasting can be used to adjust daily case counts for occurred‐but‐not‐yet‐reported events. Here, we present a novel application of nowcasting to data on the current COVID‐19 pandemic in Bavaria. It is based on a hierarchical Bayesian model that considers changes in the reporting delay distribution over time and associated with the weekday of reporting. Furthermore, we present a way to estimate the effective time‐varying case reproduction number Re(t) based on predictions of the nowcast. The approaches are based on previously published work, that we considerably extended and adapted to the current task of nowcasting COVID‐19 cases. We provide methodological details of the developed approach, illustrate results based on data of the current pandemic, and evaluate the model based on synthetic and retrospective data on COVID‐19 in Bavaria. Results of our nowcasting are reported to the Bavarian health authority and published on a webpage on a daily basis (https://corona.stat.uni-muenchen.de/). Code and synthetic data for the analysis are available from https://github.com/FelixGuenther/nc_covid19_bavaria and can be used for adaption of our approach to different data.

Food fraud in the Alps? — Detection of chamois (Rupicapra rupicapra) in firm raw sausages, ham, and meat via qualitative duplex real-time PCR

BackgroundFirm raw sausages or ham from game species like chamois, red deer, or roe deer are typical meat products from the alpine regions in Germany, Italy, Austria, and Switzerland. Increased hunting effort and limited numbers make chamois meat more expensive than comparable game meat. In routine analysis at Bavarian Health and Food Safety Authority (LGL), screening of meat relevant animal species is usually performed by LCD array. However, chamois is not included on the commercial array. A simple alternative method for chamois detection in mixed products was therefore required. ResultsWe developed a duplex probe-based real-time PCR (duplex qPCR) that facilitates the specific detection of chamois and a universal eukaryotic gene as control, especially in processed meat products. Detection of chamois was sensitive (chamois DNA content of 1.25 pg/μL or 0.05% is detectable), robust (eight variations of PCR conditions tested), and specific (inclusivity and exclusivity). Detection of Eukarya in the duplex assay can be used both as an inhibition control, and as a rough estimation for the chamois content in the sample. We analysed 20 firm raw sausages with chamois as a declared ingredient. Eleven sausages were free of chamois meat, for three sausages, a ΔCq(Chamois-Eukarya) > 10 indicated the use of chamois meat as minor ingredient, and in six sausages, abundant amounts of chamois meat were detected. Furthermore, among three analysed chamois hams, one consisted of roe deer meat instead. ConclusionsThe developed duplex qPCR is an easy to use tool to verify the presence of the declared ingredient chamois meat, especially in processed meats like sausages. The considerable proportion of products lacking declared chamois meat (55% or 11/20 for firm raw sausages, 33% or 1/3 for ham), indicates the need for further controls in this non-standard food segment.

A Public Health Antibody Screening Indicates a 6-Fold Higher SARS-CoV-2 Exposure Rate than Reported Cases in Children

BackgroundAntibody responses to virus reflect exposure and potential protection.MethodsWe developed a highly specific and sensitive approach to measuring antibodies against SARS-CoV-2 for population-scale immune surveillance. Antibody positivity was defined as a dual-positive response against both the receptor-binding domain and nucleocapsid proteins of SARS-CoV-2. Antibodies were measured by immunoprecipitation assays in capillary blood from 15,771 children aged 1 to 18 years living in Bavaria, Germany, and participating in a public health type 1 diabetes screening program (ClinicalTrials.gov: NCT04039945), in 1,916 dried blood spots from neonates in a Bavarian screening study (ClinicalTrials.gov: NCT03316261), and in 75 SARS-CoV-2-positive individuals. Virus positive incidence was obtained from the Bavarian health authority data.FindingsDual-antibody positivity was detected in none of the 3,887 children in 2019 (100% specificity) and 73 of 75 SARS-CoV-2-positive individuals (97.3% sensitivity). Antibody surveillance in children during 2020 resulted in frequencies of 0.08% in January to March, 0.61% in April, 0.74% in May, 1.13% in June, and 0.91% in July. Antibody prevalence from April 2020 was 6-fold higher than the incidence of authority-reported cases (156 per 100,000 children), showed marked variation between the seven Bavarian regions (p < 0.0001), and was not associated with age or sex. Transmission in children with virus-positive family members was 35%. 47% of positive children were asymptomatic. No association with type 1 diabetes autoimmunity was observed. Antibody frequency in newborns was 0.47%.ConclusionsWe demonstrate the value of population-based screening programs for pandemic monitoring.FundingThe work was supported by funding from the BMBF (FKZ01KX1818).

Transformation processes in Germany’s health resorts and spas – a three case analysis

ABSTRACT Germany’s traditional health resorts and spas have undergone far reaching transformation processes, triggered mainly by health care system reforms that started in the 1990s and resulted in significant cuts to the public funding of traditional restorative ‘Kur’ treatments in these destinations. Consequently, there has been a significant shift towards Germany’s so-called ‘second health care market’, which captures all privately funded health-related products and services. This paper provides an insight into these highly complex transformation processes using three Bavarian health resorts and spas (Bad Birnbach, Bad Füssing and Bad Griesbach) as case examples. Semi-structured interviews with experts from the three destinations offer insight into the structural transition towards the second health care market, including its manifold challenges and opportunities in an emerging health-leisure nexus.

Covid-19: An ad hoc public health ethics consultation

ZusammenfassungIn diesem Dokument beschreiben wir den Prozess und den Inhalt einer ad hoc Public-Health-Ethikberatung vom 22. März 2020 für eine regionale Gesundheitsbehörde (Bayerisches Landesamt für Gesundheit und Lebensmittelsicherheit) zu Entscheidungen im Zusammenhang mit Covid-19.

Evaluation of Universal Newborn Hearing Screening and follow-up

Universal newborn hearing screening (UNHS) was established in Germany in 2009. Even compliance was tested in early studies, there is little knowledge regarding the follow-up examination of children with suspected hearing disorder. A retrospective evaluation was performed in 570cases of children who failed newborn hearing screening for the years between 2009-2016. Hearing deficiency was defined as having a hearing threshold ≥ 35 dB. Compliance with national guidelines was checked. Every child received brainstem evoked response audiometry (BERA). Permanent hearing disorder was found in 24 %, of whom about half (51 %) had an inner ear hearing loss (of these in 73 % bilateral). Only 27 % of high risk children born in peripheral hospitals were tested immediately by the envisaged automated auditory brainstem response (AABR) method. They often presented tardy, leading to a delayed diagnosis and therapy. Children tracked by the Bavarian health office presented little earlier but had less cases who were lost to follow-up. In 93 % a diagnosis was made during first examination and therapy (e. g. prescription of hearing aids) initiated on average within four months age. The rate of deafness corresponded with national averages. The quality of primary screenings is crucial in revealing problems and avoiding delay in dealing with them.

Molecular biological species identification of animal samples from Asian buffets

In 2015, the Bavarian Health and Food Safety Authority (Bayerisches Landesamt fur Gesundheit und Lebensmittelsicherheit) initiated controls of Asian buffets to verify declaration of animal species. Especially Mongolian buffets, where raw meat of partly exotic animal species is offered with side dishes and sauces, enjoy high popularity in Germany. A total of 27 samples were collected in 5 Bavarian cities including nine mammalian meat, 1 frog, 3 crocodile, 10 fish, 1 squid, 2 shrimp, and 1 mussel sample. All samples were analyzed using molecular biological methods. The animal species was identified by DNA sequencing of the mitochondrial genes cytochrome c oxidase subunit I, cytochrome b or 16S ribosomal DNA with subsequent database mining. From the 27 samples, 5 were objectionable with either wrong or incomplete labelling. These included two fish samples, two samples falsely declared as zebra which were in fact beef, one guanaco sample which was depicted as camel and another guanaco sample which was marketed as llama. The results clearly show the need for continued surveillance of meat species in buffets covering a wide variety of meats and seafood.

Toxigenic Alternaria species: impact in cereals worldwide

Alternaria is one of the main mycotoxigenic fungal genera found in cereals worldwide. Reports of black point and leaf blight diseases associated with Alternaria on cereals are continually published and recent studies have shown the possible and significant impact their toxins may have on human health. Although, cereal grains are constantly affected by Alternaria spp. and their toxins, still little relevance is given on the subject. At the moment, tenuazonic acid in sorghum/millet-based infant food is the only Alternaria toxin regulated by an official government authority (Bavarian health and food safety authority). This review reports the complex Alternaria species taxonomy, their prevalence and ability to produce a diverse group of mycotoxins and their impact on cereal grains worldwide.

Interlaboratory Proficiency Test Using MALDI-TOF MS for Identification of Food-Associated Bacteria

An interlaboratory proficiency test using matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) to identify food-associated bacteria was performed with 16 food microbiological laboratories, comprising ten authorities, four companies, and two academic institutions using either the Bruker Daltonics MALDI Biotyper system, the VITEK MS Ruo SARAMIS, VITEK MS IVD Ruo (bioMerieux, France) or PAPMID (Mabritec AG, Switzerland). A blinded set of 15 reference strains was selected from the Bavarian Health and Food Safety Authority strain collection, comprising common food-associated bacteria. Depending on the presence in the databases and appropriate interpretation of data, mean accuracy rates between 34 and 100% were achieved for the respective bacterial species. Percentages of correct identifications were compared independence of the platform and the databases used. The influence of the sample preparation method and interpretation of results were also considered. Our results showed that the platform itself had no significant impact on credit points achieved. The use of an adequate sample preparation method, as well as correct interpretation of results, was much more decisive for the results achieved. In-house databases improved correct identifications when the demanded species was not mapped in the commercial databases.

Recent advances on Alternaria mycotoxins

Some of the secondary metabolites produced by Alternaria species have been recognized potentially harmful for human health due to their toxicity and occurrence in food commodities. Currently, there are no regulations worldwide for these mycotoxins with the exception of Bavarian health and food safety authority who decided to limit at 500 μg/kg the tenuazonic acid content in sorghum/millet-based infant food. The European Food Safety Authority (EFSA) performed a risk assessment for four of the known Alternaria mycotoxins (alternariol, alternariol monomethyl ether, tenuazonic acid and tentoxin) and established the threshold for toxicological concern (TTC) for these mycotoxins. In this review recent data on the biological activity, toxicokinetics, human exposure, modified forms and reduction strategies of the prevalent Alternaria mycotoxins are reported.

Long-Term Effectiveness of a Multifactorial Fall and Fracture Prevention Program in Bavarian Nursing Homes: An Analysis Based on Health Insurance Claims Data

ObjectiveFemoral fractures are frequently consequences of falls in nursing homes and are associated with considerable costs and unfavorable outcomes such as immobility and mortality. The purpose of this study was to examine the long-term effectiveness of a multifactorial fall and fracture prevention program in nursing homes in terms of reducing femoral fractures. DesignRetrospective cohort study. SettingNursing homes. ParticipantsHealth insurance claims data for 2005-2013 including 85,148 insurants of a sickness fund (Allgemeine Ortskrankenkasse Bayern), aged 65 years or older and living in 802 nursing homes in Bavaria, Germany. InterventionThe fall prevention program was implemented stepwise in 4 time-lagged waves in almost 1,000 nursing homes in Bavaria, Germany, and was financially supported by a Bavarian statutory health insurance for the initial period of 3 years after implementation. The components of Bavarian Fall and Fracture Prevention Program were related to the staff (education), to the residents (progressive strength and balance training, medication, hip protectors), and suggested environmental adaptations as well as fall documentation and feedback on fall statistics. MeasurementsData were used to create an unbalanced panel data set with observations per resident and quarterly period. We designed each wave to have 9 quarters (2.25 years) before implementation and 15 quarters (3.75 years) as follow-up period, respectively. Time trend–adjusted logistic generalized estimating equations were used to examine the impact of implementation of the fall prevention program on the likelihood of femoral fractures, controlling for resident and nursing home characteristics. The analysis took into account that the fall prevention program was implemented in 4 time-lagged waves. ResultsThe implementation of the fall prevention program was not associated with a significant reduction in femoral fractures. Only a transient reduction of femoral fractures in the first wave was observed. Patient characteristics were positively associated with the likelihood of femoral fractures (P < .001); women compared to men [odds ratio (OR) = 0.877], age category 2 (OR = 1.486) and 3 (OR = 1.973) compared to category 1, care level 1 compared to 2 (OR = 0.897) and 3 (OR = 0.426), and a prior fracture (OR = 2.230) significantly increased the likelihood of a femoral fracture. ConclusionsThere was no evidence for the long-term effectiveness of the fall prevention program in nursing homes. The restriction of the transient reduction to the first implementation wave may be explainable by a higher motivation of nursing homes starting first with the fall prevention program. Efforts should be directed to further identify factors that determine the long-term effectiveness of fall prevention programs in nursing homes.

Health-Monitoring-Units (GME) in Bavaria: standardized and repeated data collection of children’s health status and influential factors

Introduction Supported by the Bavarian State Ministry of health, in 2004 health monitoring units (GME) were established by the Bavarian Health and Food Safety Authority. The aim is to collect health data of children. Methods: During school entrance examinations, the parents of preschool children complete GME provided questionnaires regarding different health topics. This data is analyzed as 1) cross-sectional studies and 2) cohort studies, in which the parents and the children are repeatedly questioned. These surveys are conducted in three urban (Munich, Ingolstadt, Bamberg city) and three rural regions (Schwandorf, Günzburg, Bamberg rural district) within Bavaria. Main topics of the GME are widespread diseases like asthma and allergies and influencing factors. Results Recent analyses of the GME data indicate that the prevalence of asthma and allergies and the symptoms of preschool children were fairly stable from 2004 to 2012. Furthermore no differences between city and rural prevalence were present. After the introduction of the smoking ban in public areas in Bavaria, the passive smoke exposure of children at home decreased from 14,3% (2004) to 7,2% (2012). Respiratory diseases showed no clear association with exposure to passive smoking at home, except in 2012, were asthma was associated with the general smoking behavior (includes smoking outside) of parents (OR=1.6; 95% KI [1.1-2.3]). Conclusion The GME provide standardized and repeated cross-sectional as well as longitudinal data that allow monitoring the health status of children and influencing factors. In the past, prevention programs regarding obesity and ultraviolet radiation exposure have already been evaluated using GME. Furthermore with the GME it is possible to monitor potential health effects of relevant changes in legislation, such as the smoking ban. The potential of GME data is underlined by its current use in the analysis of associations between pollen records and children’s allergic sensitization.

Primary Prevention And Health Promotion in Bavaria: Taking Stock

Background: Health promotion and prevention are key elements of Bavarian health policy and are currently being re-oriented along the framework of the "Bavarian Prevention Plan". In this context, a stock taking of prevention and health promotion in Bavaria was conducted with the aim to contribute to the continued strategic and quality-orientated development of this field. Methods: The investigation was restricted to activities of primary prevention and health promotion with a focus on the action areas of the Bavarian Prevention Plan. The prevention actors, not projects, were the smallest units that were surveyed. During the 3-month field phase in 2014/2015, 595 prevention players were contacted and asked to complete an online questionnaire on their activities and target groups as well as quality and structural aspects. In addition, 9 expert interviews were conducted in an urban and a rural area in order to explore the field of small commercial and civic prevention actors. Results: 135 prevention players took part in the survey (return rate 23%). The most commonly cited themes of activities are health literacy (62% of players) and mental health (58%). The target groups are often broadly defined, gender specific measures and those for socially disadvantaged groups are comparatively rare. Provision of health-related information is the most commonly used approach (58-69% of players depending on the action area), least used are community work approaches (9-12%). 77% of the respondents state to use models of best practice and 55% scientific results in the development of measures; 43% conduct outcome evaluations and 80% take part in committee work and networks. The latter are mainly used to exchange information (90% of actors), 55 and 54% state to use them for joint planning and delivery of interventions, respectively. Conclusions: The most important prevention players took part in the survey. Methodologically it proved difficult to achieve a meaningful depiction of central aspects of the prevention scene via a quantitative survey approach. There is a lack of well-tried instruments and approaches for such cross-agency surveys. Nevertheless, the study allows trend statements on the spectrum, structure and quality of prevention in Bavaria. Thus, a starting line for the implementation of the Bavarian Prevention Plan as well as the basis of prevention reporting as intended by the new national prevention law could be established.

Taking Care of Asylum Seekers: Occupational Health Aspects with a Special Focus on Vaccination

Employees and volunteers often feel insecure about the potential transmission of infectious diseases when taking care of asylum seekers. It could be shown that overall only a minor risk of infection emanates from asylum seekers. However, aspects of occupational health and vaccination should be kept in mind.Besides the standard vaccination the Standing Committee on Vaccination (STIKO) recommends for occupational indication, which is given for employees and volunteers in asylum facilities, vaccination against hepatitis A, hepatitis B, polio (if the last vaccination was more than 10 years before) as well as influenza (seasonal).According to the German Occupational Safety and Health Act taking care of the employer has to determine which exposures might occur at the workplace (risk assessment) and define necessary protection measures. Depending on task and exposure when taking care of asylum seekers different acts (e. g. biological agents regulation) and technical guidelines for the handling biological agents (e. g. TRBA 250 or TRBA 500) have to be applied.The Bavarian Health and Food Safety Authority (LGL) has published several information sheets regarding "asylum seekers and health management" for employees and volunteers from the non-medical as well as the medical area (www.lgl.bayern.de search term "Asylbewerber"). With theses publications insecurities in taking care of asylum seekers should be prevented. Furthermore the employer gets support in the implementation of legal obligations to ensure occupational safety for the employees.

Optimierung der kommunalen Gesundheitsversorgung: Erste Erfahrungen des Kommunalbüros für ärztliche Versorgung des Landes Bayern

Background: Demographic changes pose serious challenges for the healthcare system. One important goal is to sustain the local healthcare provision in the future - especially in rural areas. In this context, more attention must be given to the statutory health service by communal as well as state authorities. Most of the municipalities have to tackle this problem for the first time and, due to lack of support, are faced with serious impediments. The aim of this paper is to describe the sphere of action of the Office for Medical Care in Districts and Municipalities (OMCDM) as well as its core outcome. Methods: The Bavarian Ministry of Health and Care (StMGP) established the OMCDM at the Bavarian Health and Food Safety Authority to support communal authorities. On behalf of the StMGP, this office analyses the existing set-ups of local health services and advises local authorities on improvement. For 2012-2015, the OMCDM database was analyzed for frequency and main reasons of contact with health services. Results: The action of the OMCDM is driven by a comprehensive assessment, specialist counseling, and networking to develop action potential for the individual local health authorities. Over the past four years, there has been an increasing demand for support. Until 2015-11-30, 233 cases of counseling and 155 intensive counseling cases were recorded. The topics most frequently mentioned in these consultations were primary care by General Practitioners (68%) and specialist care (29%). Other important issues were the search for successors (33%), the establishment of new practices (23%) and opening of branch practices (18%). Conclusion: On behalf of Bavarian government, the OMCDM offers easy access to objective and neutral counseling about statutory health services for Bavarian municipalities. This offer has been used frequently by districts and municipalities. Primary care by general practitioners on the local level was the most common reason to contact the OMCDM. The establishment of the Office for Medical Care in Districts and Municipality is a comprehensive support for local authorities and can be regarded as a pattern for other states in Germany.

Networking, Coordination and Responsibilities based on Health Regionsplus: New Health Political Approaches and Developments in Bavaria

For many health and health-care problems in the population, there is a need for professional management and coordination instruments as well as a competent local network. The new "Health Regionsplus" in Bavaria offer such a structure. This new concept is presented in the following article. The "Health Regionsplus" aim to improve the population's health, the health-related quality of life, equity in health, as well as to further develop the local health care. The Bavarian State Ministry of Health and Care will support up to 24 regions with a funding of up to 50 000 Euro yearly per "Health Regionplus" until the end of 2019. The structure of "Health Regionsplus" implies the establishment of a coordinating agency that works as a "motor", a health forum on the strategic level and relevant working groups. "Health Regionsplus" involve all relevant stakeholders of the regional health system and are chaired by the district administrator or mayor. They work primarily in the fields of health care and prevention/health promotion but can also pursue other region-specific fields. The Bavarian Health and Food Safety Authority supports and evaluates the "Health Regionsplus". There is also a coordinating office which organises the exchange of information and experience among the "Health Regionsplus". Although such a comprehensive regional approach does not change the statutory decision-making structures and responsibilities it does offer the communities an instrument to involve local needs in their decision-making processes.

Systematic and mandatory monitoring by the public health authorities – a novel approach to improve infection control and increase patient safety

Although infection control is the main responsibility of hospitals themselves the public health system has its own important role in enhancing patient safety. The increasing threat of multiresistant bacteria and outbreaks of nosocomial infections gave a reason to restructure the tasks and responsibilities of the Bavarian public health service in 2010.