Puumala orthohantavirus (PUUV) causes most human hantavirus disease cases in Europe. PUUV disease outbreaks are usually synchronized Germany‐wide driven by beech mast‐induced irruptions of its host (bank vole, Myodes glareolus). Recent data indicate high vole abundance, high PUUV prevalence and high human incidence in summer 2019 for some regions, but elsewhere values were low to moderate. This significant lack of synchrony among regions in Germany is in contrast to previous studies. Health institutions need to be informed about the heterogeneous distribution of human PUUV infection risk to initiate appropriate actions.

The study highlights the gap between legislation and the reality of restricted access to medical services for undocumented migrants in Germany. It underlines the need of increased financial and human resources in Public Health Authorities and, overall, the simplification of national legislation to assure the right to healthcare.

Zusammenfassung Die Leptospirose ist eine Zoonose, die bei Mensch und Tier eine große Bandbreite von Krankheitssymptomen mit sehr milden bis hin zu sehr schweren Verläufen aufweisen kann. In Deutschland ist der Labornachweis einer akuten Infektion meldepflichtig: beim Menschen gemäß Infektionsschutzgesetz und bei Schweinen und Schafen gemäß der Verordnung über meldepflichtige Tierkrankheiten. Die Übertragung erfolgt über direkten und indirekten Kontakt mit dem Urin infizierter Tiere, wobei Nagetiere als Hauptreservoir gelten. Mit einer durchschnittlichen jährlichen Inzidenz von 0,1 gemeldeten Fällen pro 100.000 Einwohner ist die Leptospirose in Deutschland eine seltene Erkrankung.

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Public welfare on a municipal level for groups with special health risks has been an important topic of public health service for more than a century. This notion has been taken up by the German "Protection against Infection Act" (IfSG) in § 19 IfSG. Local health service authorities may provide out-patient treatment in addition to counselling and diagnosis for patients with sexually transmitted infections and tuberculosis, which is covered by public resources in cases of apparent need. Due to altered legislation and increased global mobility, this may become important for migrants without access to regular health care.Aims of this study were recording, counselling, diagnosis and out-patient treatment of migrants without legal residence status under the German Protection against Infection Act in the public health care system.An electronic mail survey of all local health authorities (n=384) by means of a standardised questionnaire was undertaken. Data were analysed using descriptive statistics. In the annex of the questionnaire the participants were asked to describe a case study.139 of 384 local health authorities completed the questionnaire (36.2%) of whom approximately a quarter (24.6%) described contacts to "illegal" migrants. Contacts to migrants without legal residence status are more frequent in cities with more than 100,000 inhabitants than in ismaller cities (p<0.05). 22.6% of all local health authorities make an effort to reach undocumented migrants for counseling and diagnosis. 25 of the local health authorities (18.4%) indicated the capability to provide treatment in accordance with § 19 IfSG. A majority of these local health authorities also have contacts to undocumented migrants (75%). 16 local health authorities (13.3%) provide out-patient treatment for diseases not listed in Protection against Infection Act. 56 authorities (46.7%) refer patients to aid organisations or to resident doctors.Only a small number of local health authorities have contacts to migrants without health insurance. The option-al out-patient treatment is provided by few local health authorities especially in cases of sexual transmitted diseases except for HIV/AIDS. In most cases undocumented migrants are only one group among others. The large number of cases in cities with more than 500,000 inhabitants shows the massive requirements.

RESULTS indicate that the provision of care for people without health care insurance represents an important issue for a majority of the assessed hospitals since they have to take the responsibility for treatment costs in many cases. Moreover, the term "medical emergency" can be differently interpreted. Due to the inconsistent processing of cases and confusing legislation, a low-threshold health care access for (undocumented) migrants is not available. The actual legal system may result in disease progression because of uncertainty on the part of hospitals and migrants; it is also inadequate in case of emergency.

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