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Sektion Epidemiologie und Biostatistik 1
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Institut für Public Health
Institute of Public Health
Sektion Epidemiologie und Biostatistik
Unit of Epidemiology and Biostatistics
Bericht ● Report
2009-2013
2 Bericht 2009-2013
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Inhaltsverzeichnis ● Table of Contents
Einleitung ● Introduction ......................................................................................................... 4
1. Forschung ● Research............................................................................................. 7
1.1. Gemeinsame Projekte mit dem CRSN, Nouna, Burkina Faso und dem INDEPTH Network,
Accra, Ghana ●
Joint Projects with the CRSN, Nouna HDSS, Burkina Faso and the INDEPTH network, Accra,
Ghana.................................................................................................................... 7
1.2. Weitere infektionsepidemiologische Studien ●
Further studies in infectious disease epidemiology ...................................................... 15
1.3. Krebsepidemiologie ●
Cancer epidemiology .............................................................................................. 18
1.4. Sozialepidemiologie und Migrantenforschung ●
Social epidemiology and migrant research ................................................................. 21
1.5. Die Nationale Kohorte (NaKo) ●
The German National Cohort (NaKo) ........................................................................ 25
1.6. Biostatistische und epidemiologische Methoden ●
Biostatistical and epidemiological methods ................................................................ 26
1.7. Epidemiologie des Schlaganfalls ●
Stroke Epidemiology .............................................................................................. 28
1.8. Gesundheit von Müttern und Kindern ●
Maternal and child health ........................................................................................ 30
1.9. Sonstige Projekte ●
Other projects ....................................................................................................... 35
2. Lehre ● Teaching .................................................................................................. 37
2.1. HeiCuMed ............................................................................................................. 37
2.2. Wahlfach „Global Health“ ....................................................................................... 40
2.3. Graduiertenkolleg 793 ● PhD program 793 .............................................................. 40
2.4. MSc International Health ........................................................................................ 42
2.5. Weitere Vorlesungen ● Other Lectures ...................................................................... 43
3. Weitere Aktivitäten ● Further activities ................................................................ 46
3.1. Tätigkeiten in Gremien, als Editor oder Reviewer ●
Council memberships, reviewing and editorial tasks .................................................... 46
3.2. Organisation von Tagungen und Workshops ●
Organisation of meetings and workshops .................................................................. 48
4. Mitarbeiter, Kooperationspartner, Drittmittel ●
Staff, Collaborators, Funding ................................................................................ 54
4.1. Mitarbeiter ● Staff ................................................................................................. 54
4.2. Frühere Mitarbeiter ● Previous staff members ............................................................ 59
4.3. Drittmittel ● Grants................................................................................................ 60
5. Publikationen, Hochschulschriften ● Publications and Theses .............................. 63
5.1. Publikationen 2009-2013 ● Publications 2009-2013 .................................................... 63
5.2. Hochschulschriften ● Academic theses ...................................................................... 70
Sektion Epidemiologie und Biostatistik 3
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Vorwort ● Preface
Das Fach Epidemiologie ist an der Medizi- Epidemiology is
nischen Fakultät der Universität Heidelberg represented at the
innerhalb des Instituts für Public Health Medical Faculty of
repräsentiert. Dieser Bericht beschreibt die Heidelberg
Aktivitäten der Sektion Epidemiologie und University as a unit
Biostatistik in den Jahren 2009 bis 2013. within the Institute
of Public Health. In
Die Sektion hat im Berichtszeitraum eine Reihe
this report the
von Veränderungen erfahren. Insgesamt ist die
activities of the unit
Sektion stark gewachsen – bei gleichbleibender
“Epidemiology and
institutioneller Förderung. Das Drittmitte-
Biostatistics” in the
laufkommen hat sich deutlich gesteigert, und
years 2009 until
dazu haben eine Reihe von Mitarbeitern
2013 are described.
beigetragen.
The unit experienced a number of major
Zwei Mitarbeiter - Herr Dr. Heribert Ramroth
changes within the reporting period. Overall,
und Frau Dr. Sabine Gabrysch - haben sich
the unit has strongly increased in size – with
habilitiert bzw. ihre Habilitationsschrift
constant institutional support. This was only
eingereicht, für einen weiteren, Herr Dr. Volker
possible through increased external funding, to
Winkler, ist der Weg dahin nicht mehr weit.
which several members of the unit have
Alle haben selbständig Drittmittelprojekte
contributed.
eingeworben, wobei die Nachwuchsgruppe von
Frau Gabrysch im Rahmen des Two members of the unit completed their
Förderprogramms Epidemiologie des BMBF “habilitation” resp. submitted the thesis, Dr.
besonders hervorzuheben ist. Heribert Ramroth and Dr. Sabine Gabrysch,
and another member, Dr. Volker Winkler, will
Aus Anlass der Erstellung dieses Berichts
follow soon. All of them have independently
möchte ich mich herzlich bei allen
acquired research funding. The junior group of
Kooperationspartnern für die angenehme
Dr. Gabrysch under the funding scheme of the
Zusammenarbeit bedanken. Besonders
BMBF is of particular relevance.
hervorheben möchte ich die Kollegen am
„Centre de Recherche en Santé de Nouna“ I would like to thank all colleagues for the
(CRSN) in Nouna, Burkina Faso. smooth collaboration over the last years. In
particular to be named are the colleagues at
Mein Dank gilt auch allen Mitarbeiterinnen und the Centre de Recherche en Santé de Nouna“
Mitarbeitern des Instituts für Public Health, und (CRSN) in Nouna, Burkina Faso. My special
ganz besonders allen Mitgliedern meiner thanks goes to all members of the Institute of
Sektion für die vertrauensvolle und Public Health, in particular all members of the
konstruktive Unterstützung. unit, for trustful and constructive support.
Heidelberg, im November 2013
Prof. Dr. Heiko Becher
Leiter der Sektion und stv. Direktor
Head of Unit and Deputy Director
4 Bericht 2009-2013
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Einleitung ● Introduction
Epidemiologie hat in Deutschland eine Epidemiology has a relatively short tradition in
vergleichsweise kurze Geschichte. In den Germany. A few such research departments
achtziger Jahren des letzten Jahrhunderts existed in the eighties of the last century. This
existierten nur wenige Lehrstühle in diesem however has clearly changed. By now, there
Fach. Mittlerweile gibt es an vielen are institutes or departments of epidemiology
Universitäten Deutschlands eigenständige in many universities in Germany. In Heidelberg
Institute für Epidemiologie. In Heidelberg the growth of the field began in 1986 with the
begann der Aufschwung der Epidemiologie im appointment of a new professor in
Deutschen Krebsforschungszentrum mit der epidemiology to head a new Department of
Neubesetzung der Abteilungsleitung im Jahr Epidemiology (formerly medical documentation
1986 und Umbenennung der ehemaligen and statistics) at the German Cancer Research
Abteilung medizinische Dokumentation und Center (DKFZ). The establishment of further
Statistik in die Abteilung Epidemiologie. departments of epidemiology were installed at
Weitere Gründungen epidemiologischer the DKFZ and at the German Center for
Abteilungen im DKFZ und im Deutschen Research on Ageing – now merged with the
Zentrum für Alternsforschung – mittlerweile in DKFZ- which led to a significant development
das DKFZ integriert - brachten einen weiteren of the field in Heidelberg.
Aufschwung des Faches in Heidelberg mit sich.
At the medical faculty of the University of
An der Universität Heidelberg wurde eine Heidelberg there was still no department of
entsprechende Abteilung nicht eingerichtet, Epidemiology. There were nevertheless some
und es fanden nur einige epidemiologische epidemiological activities which took place
Aktivitäten innerhalb verschiedener klinischer within different clinical departments or other
Abteilungen oder in Instituten statt. Eng institutes. Closely linked to Epidemiology is the
verbunden mit der Epidemiologie ist die field of Biostatistics. This subject is well
Biostatistik. Die Biostatistik ist in Heidelberg represented at Heidelberg University by the
seit langer Zeit mit der Abteilung „medizinische reputable Department of Medical Biometry,
Biometrie“ sehr gut vertreten, allerdings mit however, it has its focus on clinical trials and
deutlichem Schwerpunkt auf Klinischen Studien not on methods in epidemiology.
und weniger auf biostatistischer Methoden-
In 1998 a new position for a professor of
forschung in der Epidemiologie.
Epidemiology and Biostatistics was created at
Im Jahr 1998 wurde an der medizinischen the Medical Faculty of the University of
Fakultät der Universität Heidelberg eine C3- Heidelberg, assigned to the Department of
Professur für Epidemiologie und Biostatistik Tropical Hygiene and Public Health at the
eingerichtet, die am damals existierenden Institute of Hygiene with the additional
Hygiene-Institut in der Abteilung responsibility of being deputy head of this
Tropenhygiene und öffentliches Gesundheits- relatively large department with about 60
wesen angesiedelt wurde. Die Besetzung dieser members. A working group Epidemiology and
Professur war verbunden mit der Biostatistics was established which became an
stellvertretenden Abteilungsleitung dieser official unit (section) under the statutes of the
relativ großen Abteilung mit ca. 60 faculty in 2003.
Mitarbeitern. Der damit verbundenen
Milestones in the development of the unit were
informellen Gründung einer „Unit of
two projects within the collaborative research
Epidemiology und Biostatistics“ folgte im Jahr
grant SFB 544 “Control of Tropical Infectious
2003 die formale Schaffung der Sektion
Diseases” which ended in 2011, and the PhD
Epidemiologie und Biostatistik.
Program (Graduiertenkolleg 793) for
Meilensteine in der Entstehung und epidemiology “Epidemiology of communicable
Entwicklung der Sektion waren die and chronic, non-communicable diseases and
Projektleitung von zwei Teilprojekten des SFB their interrelationships”, which was funded
544 „Kontrolle tropischer Infektions- from 2002 to 2012, and of which the head of
krankheiten“, der mittlerweile beendet ist, und this unit was the speaker.
die Gründung und Förderung durch die DFG
There are a number of different areas of
des Graduiertenkollegs 793 „Epidemiologie
research in the unit. These include studies in
übertragbarer und chronischer, nicht
infectious disease epidemiology, with focus on
übertragbarer Erkrankungen und deren
malaria, studies of chronic diseases – among
Wechselbeziehungen“, welches eine Laufzeit
these studies in cancer epidemiology and
von 2002-2012 hatte, und dessen Sprecher der
stroke epidemiology – studies in social
Sektionsleiter war.
epidemiology with focus on migrants from the
Sektion Epidemiologie und Biostatistik 5
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Die Forschungsthemen innerhalb der Sektion former Soviet Union, so-called “Aussiedler”,
sind vielfältig. Sie beinhalten infektions- descriptive studies with focus on data quality
epidemiologische Studien im Bereich Malaria, for health statistics in Africa, biostatistical
Studien zur Epidemiologie chronischer research projects and others. An important
Krankheiten – darunter Krebs, Schlaganfall -, area is also the methodological support of
sozialepidemiologische Studien zu Migranten, studies performed by other members of the
Studien im Bereich der deskriptiven department or of the SFB. This large variety of
Epidemiologie und Gesundheitsbericht- topics is easily explained. Epidemiological
erstattung in Afrika, biostatistische Forschungs studies are usually long-term studies, and
projekte und andere. Diese Vielfalt hat often new projects directly develop from these.
verschiedene Gründen. Epidemiologische For example, the case-control study on
Studien sind in der Regel Langzeitprojekte, bei laryngeal cancer which started in collaboration
denen sich sinnvolle Folgeprojekte aus der with the Department of Otolaryngology at
Thematik heraus ergeben. Beispielsweise ist Heidelberg University Clinics in 1996, is an
die Fall-Kontroll-Studie zum Larynxkarzinom, ongoing project up to the present day, in which
die bereits 1996 zusammen mit der HNO- results are still produced and corresponding
Universitätsklinik in Heidelberg begonnen publications have been emerged and more are
wurde, bis zum heutigen Tag ein aktuelles expected in the future. The head of the unit
Projekt, bei dem zahlreiche Erkenntnisse und who moved from the German Cancer Research
entsprechende Publikationen entstanden sind Center (DKFZ) to the Department of Tropical
und noch entstehen werden. Der Wechsel des Hygiene and Public Health brought with him
Sektionsleiters von dem Deutschen the new fields of research which are a focus
Krebsforschungszentrum an das Institut für today and will remain a focus in the future.
Public Health, brachte die oben genannten
A new large project which already attracted
neuen Themenfelder mit sich, die heute einen
much public attention is the so-called “German
breiten Raum einnehmen und auch in der
National Cohort (NaKo)”. The head of this unit
Zukunft einnehmen werden.
is the representative of the University of
Einen breiten Raum nimmt seit dem Jahr 2010 Heidelberg in the union (German: Verein)
die sogenannte „Nationale Kohorte (NaKo)“ which has been founded for administrating this
ein, bei der der Leiter der Sektion der Vertreter study. For this project, which is the largest
des dazu gegründeten Vereins für die epidemiological study ever performed in
Universität Heidelberg ist. Unter seiner Leitung Germany, the joint responsibility for the
fanden eine Reihe von Machbarkeitsstudien recruitment center Mannheim lies with our unit
statt, die zur Vorbereitung der Erhebung der together with the department of Cancer
Kohorte durchgeführt wurden. Für dieses Epidemiology at the DKFZ.
bisher größte epidemiologische Projekt in
In 2012 a call for new epidemiology units and
Deutschland liegt die gemeinsame
junior working groups was issued by the
Verantwortung für das Rekrutierungszentrum
German Ministry of Education and Research.
Mannheim bei unserer Sektion gemeinsam mit
Our unit was successful in an application to
der Abteilung Krebsepidemiologie am DKFZ.
install a new independent working group within
Eine Ausschreibung des BMBF zur Stärkung der the unit. The group is headed by Dr. Sabine
Epidemiologie in Deutschland erfolgte im Jahr Gabrysch. The funding period is for initially six
2012. Der Antrag auf eine weitere years.
eigenständige Arbeitsgruppe war erfolgreich.
Teaching also plays a major role in the unit.
Sie wird geleitet von Frau Dr. Sabine Gabrysch
The epidemiological part of the
und beinhaltet eine Projektförderung für die
“Querschnittsbereich” Epidemiology, Medical
nächsten sechs Jahre.
Biometry and Medical Informatics which is
Im Bereich der Lehre ist die Sektion vielfältig compulsory according to the new
tätig. Die Organisation der Epidemiologie im “Approbationsordnung” for medical students is
Querschnittsbereich Epidemiologie, medizi- organized by the unit head. A number of
nische Biometrie und medizinische Informatik, members of the unit as well as colleagues from
ein Pflichtbereich nach der neuen the DKFZ are involved in teaching. The
Approbationsordnung, obliegt dem epidemiological modules of the master course
Sektionsleiter. Eine Reihe von Mitarbeitern der “International Health” and other courses within
Sektion, sowie Kollegen aus dem DKFZ, sind the department are covered by the unit. The
hier an der Lehre beteiligt. Die teaching program for the former PhD program
epidemiologischen Teile der Masterprogramme has also been organized by our unit. This is
und anderer Kurse an der Abteilung werden further outlined in the report, as well as further
von der Sektion bestritten. Das Lehrprogramm scientific activities within and outside the
für das Graduiertenkolleg wurde ebenfalls medical Faculty of the University of Heidelberg.
organisiert. Dies ist in dem Bericht weiter
6 Bericht 2009-2013
___________________________________________________________________________________________
aufgeführt, sowie auch weitere In terms of publications and grant acquisition
wissenschaftliche Aktivitäten innerhalb und our unit was quite successful over the last five
außerhalb der Fakultät. years. The number of peer-reviewed
publications exceeded 100, many of these in
Die Sektion war in den letzten Jahren in Bezug
the highest ranked journals of our field. The
auf Publikationen und Drittmitteleinwerbungen
corresponding list of publications as well as a
recht erfolgreich, so wurden in dem
list of projects funded with soft money are
Berichtszeitraum insgesamt über 100
given at the end of this report.
Zeitschriftenbeiträge veröffentlicht, viele davon
in den besten Zeitschriften unseres Faches. Most parts of this report are given in German
Das Verzeichnis der Veröffentlichungen und and English, indicated by the print color. The
eine entsprechende Aufstellung der description of scientific projects, however, is
geförderten Drittmittelprojekte findet man am given in English only.
Ende dieses Berichts.
Der Bericht ist größtenteils in Deutsch und
Englisch verfasst. Aus Platzgründen sind die
Beschreibungen der wissenschaftlichen
Projekte nur auf Englisch enthalten.
Abb. 1: Campus „Im Neuenheimer Feld“ mit Institut für Public Health im
Gebäude 324
Fig. 1: New University Campus „Im Neuenheimer Feld“ with Institute of Public
Health in building 324
Sektion Epidemiologie und Biostatistik 7
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1. Forschung ● Research
In diesem Kapitel werden die wesentlichen In this chapter the main ongoing research
Forschungsprojekte des Berichtszeitraums kurz activities of the reporting period are briefly
beschrieben, wobei ebenfalls ein Ausblick auf described. This includes completed and
laufende und geplante Projekte eingeschlossen ongoing projects as well as projects in
ist. Für jedes Projekt bzw. jeden preparation. For each project or topic the
Themenbereich sind die beteiligten Mitarbeiter names of the internal working group and of the
und externen Kooperationspartner genannt. external collaborators are given. The project
Der bzw. die Projektleiter ist bzw. sind leader(s) is (are) underlined (if applicable).
unterstrichen (falls zutreffend).
Publications are listed for each project with the
Publikationen aus den jeweiligen Projekten sind number that refers to the publication list at the
mit der Nummer angegeben, die sich auf die end of the report.
Publikationsliste am Ende des Berichts bezieht.
1.1. Gemeinsame Projekte mit dem CRSN, Nouna, Burkina
Faso und dem INDEPTH Network, Accra, Ghana ●
Joint Projects with the CRSN, Nouna HDSS, Burkina
Faso and the INDEPTH network, Accra, Ghana
Mit Anfang des SFB 544, der mittlerweile With the special research grant SFB 544, which
ausgelaufen ist, begann eine enge Kooperation has now ended, we started a close
mit dem „Centre de Recherche en Santé de collaboration with the „Centre de Recherche en
Nouna“ (CRSN) in Nouna, Burkina Faso, auf Santé de Nouna“ (CRSN) in Nouna, Burkina
dem Gebiet der Epidemiologie, die auch über Faso. This collaboration with joint
den SFB hinaus in zahlreichen Projekten epidemiological projects continued after the
fortgesetzt wird. SFB has ended.
Basis der in diesem Kapitel beschriebenen Basis of all studies described in this chapter is
Studien ist jeweils ein so genanntes „Health a so-called „Health and Demographic
and Demographic Surveillance System Surveillance System (HDSS)“, which exists in
(HDSS)“, welches in Nouna seit 1993 existiert, Nouna since 1993, and in which a population of
und in dem eine Population von gegenwärtig currently more than 80000 persons is under
über 80000 Personen unter konstanter constant demographic surveillance. This HDSS
demografischer Surveillance ist. Dieses HDSS and major projects which emerged from this
ist mit den sich daraus ergebenden Projekten database are described in a review article (Sie
in einem Übersichtsartikel (Sie et al., 2010) at el., 2010) [26].
[26] beschrieben.
Publication: [26]
Abb. 2: Dorf im Distrikt Kossi, Burkina Faso
Fig. 2: Village in district Kossi, Burkina Faso
8 Bericht 2009-2013
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Risikofaktoren, zeitliche und räumliche Muster der Sterblichkeit
in Burkina Faso
Risk factors, temporal and spatial patterns of mortality in
Burkina Faso
Project team: Heiko Becher, Anja Schoeps, Gisela Kynast-Wolf, Sabine Gabrysch, Heribert Ramroth,
Gabriele Stieglbauer, Robert Ndugwa
Collaborators within the Institute: Olaf Müller, Valerie Louis, Manuele De Allegri,
External collaborators: Louis Niamba, Ali Sié, Bocar Kouyaté, Corneille Traoré, Maurice Yé, Nouna,
Burkina Faso
Funding: DFG (SFB 544) and GRK 793
closest health facility was obtained for both the
The database of the HDSS in Nouna, Burkina
dry and the rainy season, and its effect on
Faso and the collaboration with the scientists
infant (
Sektion Epidemiologie und Biostatistik 9 ___________________________________________________________________________________________ significantly related to mortality in old ages. wave’ effect appears to be observable also in Cardiovascular mortality varies by season, with areas with hot average temperatures. higher mortality rates in the hot dry season. The pattern seems to be consistent with other studies suggesting association between hot weather and cardiovascular disease. A ‘heat- Publications: [8], [19], [42] Räumliche Muster der Kindersterblichkeit Spatial Clustering of childhood mortality Project team: Heiko Becher, Gisela Kynast-Wolf, Robert Ndugwa, Heribert Ramroth, Gabriele Stieglbauer Collaborators within the institute: Olaf Müller External collaborators: Osman A. Sankoh, INDEPTH Network, Ghana and HDSS sites in twelve countries in Africa and Asia Funding: DFG (SFB 544), INDEPTH In an earlier analysis of the data from the DSS in Nouna, Burkina Faso, an extremely high childhood mortality was found in a particular village. Spatial scan statistics was the method used for the analysis. In an ongoing analysis, we investigate whether this clustering persists after a new well has been built to improve water supply in the village. Preliminary results show that the childhood mortality has slightly decreased in the Abb. 3: Länder mit HDSS verbunden mit dem INDEPTH Netzwerk years 2000 to 2003, Fig. 3: Countries with HDSS linked with the INDEPTH network however, the mortality is still significantly higher than in the been published in a special issue of the journal neighboring villages. This result gave rise to “Global Health Action” together with an similar analyses in other HDSS sites which are editorial from H. Becher. linked together within the INDEPTH Network. We organized a workshop in Accra, Ghana to investigate such patterns. The results have Publication: [16]
10 Bericht 2009-2013
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Ermittlung der Todesursache mit Daten der “Verbalen
Autopsie”: das probabilistische InterVA
Ascertaining the Cause of Death using Verbal Autopsy Data:
The probabilistic InterVA.
Project team: Heribert Ramroth, Johanna Rankin, Eva Lorenz, Mark Ssennono, Heiko Becher
External collaborators: Ali Sié, CRSN Nouna, Burkina Faso, Peter Byass, Umea Universitet, Sweden
and others
Funding: DFG (SFB 544), Project D1
Funding period: 2008-2012
In many developing countries most deaths Difficulties in determining malaria as cause of
occur outside hospitals. Therefore verbal death in holoendemic malaria regions might
autopsy (VA), involving following up deaths result in higher discrepancies than those in
with those present at the time, has been non-endemic areas. As neither Physician Coded
shown to be a useful and often the only Verbal Autopsy nor Interpreting Verbal Autopsy
possible method for deriving cause of death results represent a gold standard, uncertainty
statistics in such settings. The most common levels with either procedure are high.
method for determining the probable cause of A subsequent project covered special aspects
death (COD) from the VA interview is Physician of the verbal autopsy (VA) questionnaires. The
Coded Verbal Autopsy (PCVA), an independent question is: How informative is so called “free
review of questionnaire data by physician(s) text” in the VA questionnaires? The free text
trained in VA coding. part serves to describe the background
An alternative method, the Interpret Verbal situation of the time before death like general
Autopsy (InterVA) model, is based on a health of the deceased, health seeking
Bayesian approach which derives posterior behavior and other information found
probabilities for causes of death given an a important to report by the relatives of the
priori distribution at population level and a set deceased. Additionally, this part is not in
of interview-based indicators. The InterVA general coded by the fieldworker doing the
model has begun to be used in developing interview in the standardized section of the
countries, most notably in the INDEPTH interview. The aim of this project was to
network. determine the impact of free text information
seeking the final cause of death. We found that
The aim of the project was to compare the there were changes of between 5.5-10.2%
COD distribution using the PCVA approach between models before and after free-text
versus the InterVA model, based on incorporation. No impact on malaria CSMFs
information from a French VA questionnaire in was seen in the representative sub-sample,
rural north-western Burkina Faso. We found but the proportion of malaria as cause of death
that at the population level, 62.5% of causes increased in the physician sub-sample (2.7%)
of death using the Interpreting Verbal Autopsy and saw a large decrease in the InterVA
model corresponded with those determined by subsample (9.9%). Information on 13/106
two or three physicians. Although seven of the indicators appeared at least once in the free-
10 main causes of death were present in both texts that had not been matched to any item in
approaches, the comparison of percentages of the structured, electronically available portion
single causes of death shows discrepancies, of the Nouna questionnaire. We concluded that
dominated by higher malaria rates found in the free-texts are helpful in gathering information
Physician Coded Verbal Autopsy approach. not adequately captured in VA questionnaires,
Our results confirm that national mortality though access to free-text does not explain
statistics, which are partly based on verbal differences in physician and model
autopsies, must be carefully interpreted. determination of malaria as cause of death.
Publications: [65, 66]Sektion Epidemiologie und Biostatistik 11
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Mangelernährung bei Kindern
Childhood malnutrition
Unit member in project team: Sabine Gabrysch
Project team at Institute of Public Health: Olaf Müller, Claudia Beiersmann, Valerie Louis,
Albrecht Jahn
External collaborators: Maurice Yé, Nouna, Burkina Faso
Funding: DFG (GRK 793)
For measurement of progress towards the (42.6%) and lowest in December 2009
Millennium Development Goal (MDG) 1, (34.1%). After adjustment for age, sex and
reliable data on nutrition indicators of specific village, there was a slight but not always
countries are essential. Malnutrition is also the significant improvement in the z-scores of
main determinant for childhood mortality, weight-for-age, weight-for-length, length-for-
which is addressed in MDG 4. In the Nouna age, and mid-arm circumference over time.
HDSS, nutritional parameters were compared The findings from this study confirm the still
in two cohorts of young children of the same unacceptable high prevalence of malnutrition in
age range from eight villages. Surveys took young children of rural sub-Saharan Africa
place in June and December of the year 1999 (SSA). We concluded that progress in the
and 2009. A multivariate model was used to reduction of malnutrition remains slow on this
control for confounding variables. Prevalence continent making it rather unlikely that the
of underweight was highest in December 1999 corresponding MDGs will be achieved.
Publication: [48]
Effekt von imprägnierten Bettnetzen im Säuglingsalter
Effects of insecticide-treated bednets during early infancy
Unit members in project team: Heiko Becher, Heribert Ramroth, Gabriele Stieglbauer
Project team at Institute of Public Health: Olaf Müller
External Collaborators: Corneille Traoré, Bocar Kouyaté, Yazoumé Yé, Claudia Frey, Boubacar
Coulibaly
Funding: DFG, SFB 544
This study was performed under the representative subsample of the study
supervision of Prof. Dr. Olaf Müller and population.
analyzed in this unit. Insecticide-impregnated After a mean follow-up of 27 months, there
bednets and curtains have been shown by were 129 deaths in group A and 128 deaths in
many studies to be effective against malaria. group B rate ratio (RR) 1.0 (95% confidence
However, because of possible interactions with interval (CI): 0.78-1.27)). Falciparum malaria
immunity development, treated bednets may incidence was lower in group A than in group
cause no effect at all or even an increase in B, during early (0-5 months) and late infancy
malaria morbidity and mortality in areas of (6-12 months) (RR 3.1, 95% CI: 2.0-4.9; RR
high transmission. To clarify this issue, we did 1.3, 95% CI: 1.1-1.6) and rates of moderate
a randomized controlled trial to assess the to severe anaemia were significantly lower
long-term effects of bednet protection during during late infancy (11.5% vs 23.3%, P =
early infancy. 0.008), but there were no differences between
Between 2000 and 2002 a total of 3387 groups in these parameters in children older
neonates from 41 villages in rural Burkina Faso than 12 months. The findings from this study
were individually randomized to receive either provide additional evidence for the efficacy of
bednet protection from birth (group A) or from insecticide-treated nets in young children living
age 6 months (group B). Primary outcomes in areas of intense malaria transmission.
were all-cause mortality in all study children
In the reporting period, a further analysis with
and incidence of falciparum malaria in a
a long-term follow-up has been performed.
After a median follow-up time of 8.3 years,12 Bericht 2009-2013
___________________________________________________________________________________________
443/3387 (13.1%) children had migrated out We conclude that insecticide-treated mosquito
of the area and 484/2944 (16.4%) had died, net protection in early infancy is not a risk
mostly at home. Long-term compliance with factor for mortality. Individual ITN protection
ITN protection was good. There were no does not sufficiently reduce malaria prevalence
differences in mortality between study groups in high-transmission areas. Achieving universal
(248 deaths in group A, 236 deaths in group ITN coverage remains a major challenge for
B; rate ratio 1.05, 95% CI: 0.889-1.237, P = malaria prevention in Africa.
0.574). The survey conducted briefly after the
rainy season in 2009 showed that more than
80% of study children carried asexual malaria
parasites and up to 20% had clinical malaria.
Publication: [60]
Optimising the impact and cost-effectiveness of child health
intervention (OPTIMUNIZE)
Unit members in Project team: Heiko Becher, Anja Schoeps
Project team members within the institute: Olaf Müller, Nobila Ouédraogo
External Collaborators: Peter Aaby, Christine Benn, Ane Fisker, Statens Serum Institut Denmark;
Instituto Nacional de Salude Publica, Guinea-Bissau; Ali Sié et al., Centre de Recherche en Santé de
Nouna, Burkina Faso; Ghana Health Service, Ghana; INDEPTH Network, Ghana and others
Funding: EU
Recent studies have consistently shown that information from existing vaccination cards
vaccines and micronutrients have non-specific ranged from 80% (measles) to 94% (OPV1).
effects, i.e. effects which are not explained by When taking into consideration all information
prevention of the targeted infections or available (including BCG scars in children with
deficiencies. These effects are often sex- and without vaccination card), full coverage in
differential. Furthermore, interventions may children aged 12–23 months was around 75%,
interact. Hence, the overall impact of child with a significantly higher coverage in rural
health programs cannot be extrapolated from compared with urban areas. There were no
small-scale target-specific studies. differences in vaccination coverage between
boys and girls. The study supports other
In this study we first used the health and
studies that found vaccination coverage
demographic surveillance system (HDSS) sites
improvement in Burkina Faso recently.
in Nouna, Burkina Faso to register information
routinely on all inter-
In a second step we
ventions in childhood,
perform a two center
such as all vaccinations,
randomised intervention
micro-nutrient
trial in Burkina Faso and
supplementation, and
in Guinea-Bissau.
de-worming, given at
health centres or in
Providing early measles
campaigns. We
vaccine at 4.5 and 9
estimated vaccination
months of age is
coverage using a data
currently being compared
set of 11 906 children
with the recommended
agedSektion Epidemiologie und Biostatistik 13
___________________________________________________________________________________________
INDEPTH Training and Research Centres of Excellence
(INTREC)
Unit members in project team: Heiko Becher, Nicholas Henschke, Heribert Ramroth
External Project team members: Osman Sankoh et al., INDEPTH Network, Ghana; Peter Byass,
John Kinsmann et al., Umea, Sweden; Joke Haafkens, Amsterdam, The Netherlands; Lisa Berkmann,
Anna Mirny, Harvard University, USA, Laksono Trisnantoro, Indonesia, Karen Hofmann, South Africa
Funding: EU
The WHO's Commission on Social presented to decision makers in an actionable,
Determinants of Health (SDH) argued in 2008 policy-relevant manner.
that the dramatic differences in health status INTREC activities will cover three African
that exist between and within countries are (Ghana, South Africa, Tanzania) and four Asian
intimately linked with degrees of social countries (Indonesia, Viet Nam, Bangladesh,
disadvantage. These differences are unjust and India) and will be concentrated in two training
avoidable, and it is the centres in Ghana and
responsibility of govern- Indonesia. The centers are
ments, researchers, and to become focal points for
civil society to work to research on social
reduce them. Part of this determinants of health in
work requires the LMICs, thus enabling
production of setting- extensive South-South and
specific, timely, and North-South networks and
relevant evidence on the research cooperation.
relationship between social INTREC approach to
determinants of health and capacity-building is holistic
health outcomes, and yet and includes both, providing
this information is limited, state-of-the-art region-
especially in low- and specific training for young
middle-income countries Abb. 5: Beteiligte Länder bei INTREC researchers, and educating
(LMICs). Thus there is a Fig. 5: Countries covered by INTREC decision-makers on social
strong need for the determinants of health. The
development of capacity- work will be carried by a
building activities to enable such research. strong Consortium team of five university-
based centres in Sweden, Germany,
INTREC has been established with this concern Netherlands, Indonesia and USA and by one
in mind and its dual aims include: research network of demographic surveillance
• Providing SDH-related training for sites in LMICs with headquarters in Ghana
The International Network for the Demographic (INDEPTH).
Evaluation of Populations and Their Health
researchers (INDEPTH), thereby allowing the INTREC approach will be evaluated at the end
production of evidence on associations of a 3.5-year period. Based on the results of
between SDH and health outcomes. this evaluation, a conceptual framework on
• Enabling the sharing of this how to build sustainable capacity for research
information through facilitating links between on health and its social determinants that
researchers and decision makers, and could be applied in other LMICs will be
byensuring that research findings are developed.
Publications: [77]14 Bericht 2009-2013 ___________________________________________________________________________________________ Weitere Studien zu Malaria in Nouna, Burkina Faso Further Studies on Malaria in Nouna, Burkina Faso Project team members in Unit: Heiko Becher, Gisela Kynast-Wolf, Gabriele Stieglbauer Project team members within the institute and the medical faculty: Olaf Müller, Michael Lanzer, Thomas Jänisch, Caroline Geiger, and others External project team members: Ali Sié, Boubacar Coulibaly, CRSN, Nouna, Burkina Faso and others Funding: DFG (GRK 793 and SFB 544) One study (Geiger et al., 2013) within the PhD treated mosquito net (ITN) trial during which program 793 aimed at assessing the dynamics neonates were individually randomized to ITN of parasite prevalence and malaria species protection from birth vs. protection from distribution over time in an area of highly month six onwards in rural Burkina Faso. A sub seasonal transmission in Burkina Faso and to sample of 120 children from three villages was compare frequency of asymptomatic followed for 10 months with six measurements parasitaemia between wet and dry season by of MSP142 antibodies (ELISA based on parasite density status and age group. Cross- recombinant 42 kDa fragment) and daily sectional studies were performed in the rural assessment of malaria episodes. Time to the village Bourasso in the Nouna Health District in next malaria episode was determined in north-west Burkina Faso. In subsequent rainy relation to MSP142 antibody titres. MSP142 and dry seasons blood samples were collected antibody titres were dependent on age, to assess the parasite prevalence, species, season, ITN-group, number of previous malaria density and clinical parameters. In total, 1,767 episodes and parasitaemia. There were no children and adults were examined and significant differences in time until the next compared to a baseline collected in 2000. The malaria episode in children with low compared microscopical parasite prevalence (mainly P. to children with high MSP142 antibody titres at falciparum) measured over the rainy seasons any point in time (101 vs. 97 days in May, p = decreased significantly from 78.9% (2000) to 0.6; 58 vs. 84 days in September, p = 0.3; 58.4%, 55.9% and 49.3%, respectively 144 vs. 161 days in March, p = 0.5). The (2009–2011; p
Sektion Epidemiologie und Biostatistik 15
___________________________________________________________________________________________
parasites. Our data suggest a selective model that the human host provides various
disadvantage of the polymorphic and a microenvironments that favor genetically
selective advantage of the wild-type pfcrt distinct P. falciparum populations.
haplotype in the placenta, supporting the
Publications: [21], [58]
1.2. Weitere infektionsepidemiologische Studien ●
Further studies in infectious disease epidemiology
Infektionskrankheiten waren das erste Feld der Epidemiology developed from research on
Epidemiologie. Ein klassisches Beispiel hierfür infectious diseases. As a classical example the
ist die Arbeit von John Snow, der Mitte des 19. work of John Snow is often cited who
Jahrhunderts die Übertragungsweise von discovered the mode of transmission of cholera
Cholera entdeckte und effektive Interventionen in the 19th century and developed an effective
vor der Entdeckung des Vibrio cholerae intervention before the agent Vibrio cholerae
entwickelte. was discovered.
Auch heute ist die Infektionsepidemiologie ein Infectious disease epidemiology is still an
wichtiger Bereich, insbesondere im important field, in particular in collaborative
Zusammenhang mit Forschung in research in low- and middle-income countries.
Entwicklungsländern. In dieser Sektion wurden In this Unit a number of studies in the field of
in Berichtszeitraum eine Reihe von Studien zu infectious diseases have been performed. If
Infektionskrankheiten durchgeführt. Soweit es these have been joint projects with the CRSN
sich um Projekte gemeinsam mit dem CRSN in in Nouna, Burkina Faso or with the INDEPTH
Nouna, Burkina Faso, oder mit dem INDEPTH network, they have already been described in
Network handelt, sind diese bereits im vorigen the previous chapter.
Kapitel beschrieben.
Vergleich von Medikamenten gegen Kopfläuse
Comparison of head lice treatment
Project team: Heiko Becher, Susanne Sonnberg
External Collaborators: Jörg Heukelbach, Fortalezza, Brasil and collaborators
Funding: DFG (GRK 793) and Bonusmittel
This was a joint project with colleagues in and fed on volunteers to obtain fertile eggs of
Fortalezza, Brasil. Head lice are common known age. Two methods of feeding were
worldwide, and effective treatment is needed. applied: interval feeding (performed every 8-
In this study ovicidal efficacy of three 12 hours), and
dimeticone products of different compositions continuous
were tested. Against feeding. The
mature eggs, NYDA following out-
outperformed all other come
products (94.9% measures
efficacy), with a were used:
significant difference to appearance of
Jacutin (73.7%; P eye spot; Fig 6a: Pediculus humanus
¼.016) and the other presence of capitis
pediculicides. embryonic
structures; presence of embryonic movements;
Fig. 6:Petrophaga Within the project, an
and hatching. Results: Eye spots of the
lorioti adaptation of historical
embryos started to appear 6 days after
methods for rearing head
oviposition (median = 7 days), and embryonic
lice was done, and their development ex vivo
movements were first seen 9 days after
was described. Adult head lice were collected16 Bericht 2009-2013
___________________________________________________________________________________________
oviposition (median 11 days). Continuous habitat, and hatch rates are high. However,
feeding of head lice on a human host is a side effects on volunteers such as skin
suitable approach to obtain head lice eggs for irritation (papular rash; moderate to severe
ovicidal testing. The method is simple and itching) occur and must be considered.
cheap, offers conditions similar to the natural
Publications: [27], [36]
Tuberkulose in Deutschland
Tuberculosis in Germany
Project team: Heiko Becher, Judith Barniol
Collaborations within the institute and the medical faculty: Thomas Junghanss
External Collaborators: Walter Haas, Berlin; Michael Forßbohm, Wiesbaden and others
Funding: DFG (GRK 793), DFG (Einzelantrag) and Bonusmittel
In one of our studies (Forsbohm et al, 2011) out in a German federal state from 2003 to
on Tuberculosis in Germany, we investigated 2005. Data for the study included: 1) case
the validity of the statistics on deaths caused data routinely collected by the local public
by TB. The study population consists of the health staff and transmitted to the state health
926 fatal cases that were classified either as office and the national surveillance centre, 2) a
“death from TB” or as “death due to other study questionnaire designed to capture social
causes”. For the analysis, health authorities interactions of relevance for TB transmission
were asked to provide additional information and 3) molecular genotyping data. Results: A
and such documents as the death certificate, total of 749 cases of culture-positive
the autopsy protocol and the final medical pulmonary tuberculosis voluntarily enrolled in
report. Based on the findings, every second the study. Forty-seven clusters, defined as at
death caused by TB in 1997 and 1998 was not least two cases infected by the same TB
recorded correctly during the postmortem strains, were identified by molecular methods
examination. Every third TB death was not and included 132 (17%) of the study
diagnosed during the patient’s lifetime. participants. Epidemiological links were
Patients who died due to TB were, on average, identified for 28% of the clusters by
older and more likely to be born in Germany. conventional epidemiological data. In mixed
clusters, defined as clusters including German
This indicates that age-related comorbidity
and foreign-born individuals, the probability of
among the native German population plays a
cases to be caused by foreign-born cases was
relevant role. Yet, the unicausal death
estimated at 18.3%. We observed a trend to
registration did not acknowledge comorbidity
mixed clusters with increasing time spent by
as a contributing factor to the fatal outcome.
immigrants in the host country. This group also
In conclusion, the post-mortem examination
presented comparatively higher integration
often missed TB as the cause of death. Many
indexes than immigrants in immigrant-only
native German TB patients showed age-related
clusters.
comorbidity. Pulmonary TB with positive
The study confirmed the findings of other
microscopy, miliary TB and meningeal TB led
studies that there is no significant TB
more often to a fatal outcome than other organ
transmission from TB high-prevalence
manifestations. Alcohol abuse was a leading
immigrant to TB low-prevalence autochthonous
risk factor for TB deaths in patients younger
population. This may be explained by the good
than 65 years.
performance of tuberculosis screening
programs for certain groups arriving in
In another study (Barniol et al., 2009) we
Germany from high- prevalence countries, by a
described how immigration influences TB
low degree of mixing of immigrants with the
transmission in Germany. A prospective study
local population or by a combination of both.
of confirmed culture positive cases of
pulmonary TB and their contacts was carried
Publications: [13], [32]Sektion Epidemiologie und Biostatistik 17
___________________________________________________________________________________________
Die Bedeutung antimikrobieller Peptide bei Hautinfektionen
The role of antimicrobial peptides in human skin infections
Unit member in project team: Sabine Gabrysch
External collaborator: Philipp Zanger, Tübingen
Funding: Core funding
Staphylococcus aureus is the most common peptide RNase 7 was 64% higher in the skin of
cause of skin infections. Presentation and control subjects than in the skin of cases, while
course of disease vary from minor self-limiting there was no difference in the expression of
infections to deep, recurrent abscesses that the antimicrobial peptides HBD-2 and HBD-3.
require surgical intervention and systemic Together with the known high baseline
antibiotic therapy. A possible explanation for expression of RNase 7, this suggests that this
these differences in disease susceptibility and AMP confers protection against skin infection.
severity has been provided by recent insights In those travellers with skin infection, we
into innate defence mechanisms of human furthermore examined AMP inducibility
skin, in particular antimicrobial peptides (AMP). (upregulation) by comparing AMP levels in
These are natural antibiotics present in the infected skin to that in healthy skin. Both HBD-
skin that are thought to prevent infection in 2 and HBD-3 were strongly upregulated by S.
the first place, or that can be upregulated in aureus infection, but not RNase 7. When
response to infection and limit the severity of comparing inducibility between patients with
disease. different severity of skin infection, we found
In the travel clinic of the Institute of Tropical that expression of HBD-3 was 11 times lower
Medicine in Tübingen, studies were conducted in patients with more than 6 recurrences and 9
among travellers returning with Staphylo- times lower in patients reporting surgical
coccus aureus-positive skin infection (cases) drainage than in the respective baseline
and healthy control subjects. groups. There was no difference in HBD-2
inducibility between severity groups. This
When examining healthy skin (from the gluteal
suggests that high inducibility of HBD-3 can
region) from both cases and controls, we could
limit the severity of skin infection.
show that expression of the antimicrobial
Publications: [30], [70]
Chronic kidney disease among HIV+ patients in Zambia
Unit member in project team: Andreas Deckert
Project team at Institute of Public Health: Florian Neuhann, Claudia Beiersmann
External collaborators: Helmut Reutter, CHRESO Ministries Zambia, Martin Zeier, Kidney Center
Heidelberg; Thomas Bruckner, Institut für Medizinische Biometrie, Heidelberg; Dietrich Rothenbacher,
Institut für Epidemiologie und Medizinische Biometrie Ulm
Funding: Else Kröner-Fresenius-Stiftung (proposal submitted)
This project plans to address the lack of long run end up in severe CKD, whose
knowledge regarding diagnosis/categorization treatment needs additional medical devices,
of chronic kidney disease (CKD) in HIV+ which are hardly available in SSA. Furthermore
patients in Sub-Saharan Africa (SSA), and chronic kidney disease (CKD) is a major cause
regarding prevalence and incidence of CKD, of morbidity and mortality particularly in low-
what will make the need of action visible to income countries. The degree and burden of
health policy. HIV prevalence in Zambia, SSA, HIV+ related nephropathy in Zambia is widely
is known to be high at about 14%. It unknown, single studies report about up to
constitutes a top public health problem and is 34% CKD prevalence among HIV-patients in
known to be jointly responsible for hampering Zambia. Measurement and definition of renal
development of the society. Among others, HIV function is challenging and can be estimated
infection can cause nephropathy and in the indirectly only in SSA by assessing the18 Bericht 2009-2013
___________________________________________________________________________________________
glomerular filtration rate (GFR), based on should be used to estimate the CKD prevalence
serum creatinine. In the region of Lusaka, among HIV+ patients, to identify CKD
Zambia, a humanitarian project was favouring anti-retroviral treatment, and to
established to provide anti-retroviral treatment establish a CKD preventive HIV treatment
to HIV+ patients. Within this project, routine scheme in the long run. In the prospective part
laboratory time-series data of some thousand we plan to establish a HIV- control group and
patients exist, starting in 2005. This data to include additional CKD risk factors.
1.3. Krebsepidemiologie ● Cancer epidemiology
Krebsepidemiologie hat sich seit dem Nachweis Cancer epidemiology developed very rapidly
des Zusammenhangs zwischen Rauchen und since the 1950s when the link between
Lungenkrebs in den fünfziger Jahren des smoking and lung cancer was discovered.
20. Jahrhunderts rasant entwickelt. Studien Studies were mainly performed in western
fanden in der überwiegenden Mehrzahl in countries, where cancer is one of the major
Industrieländern statt, in denen Krebs eine der causes of death. Studies in developing
Haupttodesursachen ist. In letzter Zeit werden countries, however, are becoming more and
auch zunehmend krebsepidemiologische more common, mainly because of the overall
Studien in Entwicklungsländern durchgeführt, increasing life expectancy and a related
bedingt durch eine insgesamt steigende increasing cancer incidence. In this Unit we
Lebenserwartung und einer damit verbundenen perform a number of cancer studies, which in
ansteigenden Krebsinzidenz. In dieser Sektion part originated as long term projects from the
werden bzw. wurden eine Reihe von Studien former position of the unit head at the German
aus dem Bereich der Krebsepidemiologie Cancer Research Center.
durchgeführt.
Rauchen und Lungenkrebs in Afrika
Smoking and lung cancer in Africa
Project team: Volker Winkler, Heiko Becher
External collaborators: Jördis Jennifer Ott, Melanie Cowan, WHO, Geneva;
Funding: GKR 793, SFB 544 and core funding
In general data on smoking prevalence is year. Tobacco is the major cause of cancer and
scarce for African countries, but an important risk factor for several other
there are several studies for chronic diseases. Due to the
different countries available that epidemiological transition in
show an alarming trend: Male developing countries
smoking prevalence in African (increasing life expectancy)
varies from about 20% up to there is an increasing
over 65% depending on age and relevance of chronic diseases
country. to the total burden of
diseases.
Traditionally, smokers are mostly
males. The proportion of women We developed a method to
smokers is very low, but is estimate the number of lung
already rising in a few African cancer cases caused by
countries. According to the WHO, smoking in Africa using lung
in 1999, Africa smoked 4% of cancer mortality data from
World cigarette consumption and Abb. 7:Lungenkrebsraten (Männer) industrialized countries only
the UN's Food and Agricultural in Afrika in combination with smoking
Organisation (FAO) state Fig. 7: lung cancer mortality rate prevalence data in Africa. The
cigarette smoking in Africa is (males) in Africa results showed, that the
growing by a record 3.5% a (Becher & Winkler, 2010) previous estimates were tooSektion Epidemiologie und Biostatistik 19
___________________________________________________________________________________________
high but on the other hand up to 50000 lung We were able to show that the estimates by
cancer deaths per year occur in Africa, most of IARC/WHO, which are based extrapolations
them caused by smoking. This number will from local cancer registries in a few African
increase due to the demographic transistion. countries are not reliable and strongly
underestimate the real burden of the disease.
We applied the model to data from countries
Even under the assumption of decrease in
where data on lung cancer mortality are
smoking prevalence, we showed lung cancer
sufficiently reliable, and found that our model
mortality will rise. The epidemiologic transition
predicts total burden of lung cancer very well.
in African low-income countries alludes to the
need for targeted health prevention efforts.
Publications: [28], [29], [31], [44], [82]
Studien zur Äthiologie und Prognose des Kehlkopfkrebs
Studies on etiology and prognosis of laryngeal cancer
Project team: Heribert Ramroth, Irene Santi, Heiko Becher
External collaborators: Odilia Popanda, Angela Risch, Peter Schmezer, DKFZ Heidelberg Andreas
Dietz, Leipzig; Wolfgang Ahrens, BIPS Bremen; and others
Funding: Dietmar Hopp foundation
The Rhein-Neckar-Larynx Study is a exposures might explain a part of the
population-based case-control study 1:3 remaining but the components and pathways
frequency matched by age and sex on of the socioeconomic contribution have yet to
laryngeal cancer in South-West Germany with be fully disentangled. One aim of this analysis
257 cases, histologically confirmed and is to evaluate the role of occupation using
diagnosed between 1.5.1998 and different occupational
31.12.2000 and 769 population indices, differentiating
controls. Information about Darmstadt between physical,
occupational exposures, lifestyle psycho-social and toxic
factors and socio demographic exposures and trying to
background were obtained with summarize the
face-to-face interviews using a occupational burden into
detailed standardized Mannheim one variable.
questionnaire. This case-control A second of these
study allowed numerous analyses Ludwigshf.
Heidelberg
analyses is to measure
and publication, some of which the extent to which the
published in this reporting period. association between
Heilbronn socioeconomic status and
Based on the data from the case
laryngeal cancer is
control study, new analyses have
mediated by smoking,
been done to better understand Abb. 8: Studienregion der Rhein- alcohol consumption and
the influence of occupation as risk Neckar-Larynx Studie occupational exposure.
factor for laryngeal cancer. Fig.8: Study region of the Rhein-
For this, a decomposition
Previous studies tried to assess the Neckar-Larynx Studie
method for logit models
association between socioeconomic
proposed by Karlson, Holm and Breen was
status and laryngeal cancer. Alcohol and
used to return the percentage of change in
tobacco consumption explain already a large
odds ratios due to confounding.
part of the social inequalities. Occupational
Publications: [107], [108]
The cases of the study have been laryngeal cancer patients, involving a variety of
supplemented by more than 500 further cases interacting factors. Five-year overall survival of
from the years 2001 to 2004 to generate a all Europeans diagnosed with laryngeal cancer
patient cohort which has been followed up until between 1995 and 1999 was 55%, slightly
June 2011. This was done to better analyse worse than survival rates for the German
those factors which influence survival of population (59%). Despite the knowledge thatSie können auch lesen
