Publications by authors named "Preben Aavitsland"

88 Publications

Measles vaccine coverage among children born to Somali immigrants in Norway.

BMC Public Health 2021 Apr 7;21(1):668. Epub 2021 Apr 7.

Division of Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway.

Background: Despite overall good vaccination coverage in many countries, vaccine hesitancy has hindered full coverage and exposed groups to the risk of outbreaks. Somali immigrant groups have been known to have low measles vaccination coverage, leading to outbreaks in their communities. Current research indicates a general lack of trust in the healthcare system, the use of alternative information sources and inadequate health literacy can be contributing factors. We explore measles vaccine coverage in children born to Somali parents in Norway, whether it has changed over time and factors that may influence coverage.

Methods: Data was extracted from the National Population Register on all children born in Norway from 2000 to 2016, where both parents originated from Somalia. Date of birth, gender, residential area at birth and date of immigration and emigration for both parents was linked to information on measles vaccination from the National Immunisation Register.

Results: We found that children born to Somali immigrants in Norway had suboptimal measles vaccine coverage at 2 years; for children born in 2016 the coverage was 85%. Coverage declined between 2000 and 2016, and at a greater rate for boys than girls. Children born to mothers residing in Norway for 6 years or more had lower coverage compared to those with mothers residing less than 2 years prior to their birth. Children born in the capital and surrounding county had significantly lower coverage than children born elsewhere in Norway.

Discussion: New targeted interventions are needed to improve measles vaccine coverage among Somali immigrants in Norway. Some possible strategies include using Somali social media platforms, improving communication with Somali parents and tighter cooperation between various countries' vaccination programmes.
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http://dx.doi.org/10.1186/s12889-021-10694-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8028092PMC
April 2021

A pandemic year draws to a close.

Tidsskr Nor Laegeforen 2020 12 14;140(18). Epub 2020 Dec 14.

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http://dx.doi.org/10.4045/tidsskr.20.0988DOI Listing
December 2020

The establishment and first experiences of a crisis advisory service for water supplies in Norway.

J Water Health 2020 Aug;18(4):545-555

Norwegian Institute of Public Health, Section of Zoonotic, Food- and Waterborne Infections, P.O. Box 222 Skøyen, 0213 Oslo, Norway E-mail:

Water supply systems, in particular small-scale water supply systems, are vulnerable to adverse events that may jeopardise safe drinking water. The consequences of contamination events or the failure of daily operations may be severe, affecting many people. In Norway, a 24-hour crisis advisory service was established in 2017 to provide advice on national water supplies. Competent and expert advisors from water suppliers throughout the country assist other water suppliers and individuals who may be in need of advice during an adverse event. This paper describes the establishment of this service and experiences from the first three years of its operation. Since the launch of the service, water suppliers across Norway have consulted it approximately one to two times a month for advice, in particular about contamination events and near misses. The outcomes have helped to improve guidance on water hygiene issues at the national level.
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http://dx.doi.org/10.2166/wh.2020.066DOI Listing
August 2020

Worried and prepared.

Tidsskr Nor Laegeforen 2020 Aug 3;140(11). Epub 2020 Jul 3.

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http://dx.doi.org/10.4045/tidsskr.20.0574DOI Listing
August 2020

Infectious diseases among patients at the Health Centre for Undocumented Migrants in Oslo.

Tidsskr Nor Laegeforen 2020 03 16;140(4). Epub 2020 Mar 16.

Background: Undocumented migrants probably fall outside the scope of public infectious disease control schemes. The article aims to describe the extent of undetected highly hazardous communicable diseases among patients at the Health Centre for Undocumented Migrants in Oslo.

Material And Method: We reviewed the records of all patients who attended the Health Centre for the first time in 2016 or 2017, with a view to age, sex, period of stay in Norway, country category and infection test results from the period 1 January 2016-31 December 2017.

Results: There were four new cases of hepatitis B among 139 patients tested, and four cases of chlamydia infection among 38 patients tested. There were no new cases of active pulmonary tuberculosis, syphilis, HIV infection or hepatitis C.

Interpretation: There were fewer cases of highly hazardous communicable diseases than what might be expected based on the countries from which the patients originated.
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http://dx.doi.org/10.4045/tidsskr.19.0074DOI Listing
March 2020

P. Aavitsland responds.

Tidsskr Nor Laegeforen 2020 03 16;140(4). Epub 2020 Mar 16.

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http://dx.doi.org/10.4045/tidsskr.20.0158DOI Listing
March 2020

The coronavirus epidemic will reach Norway.

Tidsskr Nor Laegeforen 2020 02 29;140(3). Epub 2020 Jan 29.

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http://dx.doi.org/10.4045/tidsskr.20.0077DOI Listing
February 2020

Under the skin.

Tidsskr Nor Laegeforen 2019 Nov 30;139(16). Epub 2019 Oct 30.

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http://dx.doi.org/10.4045/tidsskr.19.0643DOI Listing
November 2019

An outbreak of skin rash traced to a portable floating tank in Norway, May 2017.

Euro Surveill 2019 Sep;24(38)

Norwegian Institute of Public Health, Department of Zoonotic, Food- and Waterborne Infections,, Oslo, Norway.

Despite concerns about infection risks of floating tanks, outbreaks have rarely been reported. In May 2017, an outbreak of skin rash occurred among visitors of a floating tank open for the public in Norway. We assessed the extent and cause of the outbreak and the risk factors for infection in a retrospective cohort study among the visitors of the floating tank using a standardized web-based questionnaire. An environmental investigation was conducted including microbiological analysis of the floating tank water. Of the 46 respondents to the questionnaire (61 distributed), 22 reported symptoms, most commonly palmar and plantar rash, swollen lymph nodes, ear canal pain and itching. None of the investigated risk factors, such as sex, age, duration of bathing or use of the shower after bathing, were significantly associated with illness. The results of the environmental investigation indicated that the water was heavily contaminated by and heterotrophic bacteria. The outbreak investigation highlights the need to ensure adequate hygienic operation of floating tanks. Awareness about responsibilities should be raised among the operators of floating tanks and relevant operational parameters for floating tanks should be made available for local health authorities.
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http://dx.doi.org/10.2807/1560-7917.ES.2019.24.38.1900134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761578PMC
September 2019

Compliance with water advisories after water outages in Norway.

BMC Public Health 2019 Aug 29;19(1):1188. Epub 2019 Aug 29.

Department of Zoonotic, Food- and Waterborne Infections, Norwegian Institute of Public Health, Oslo, Norway.

Background: Water advisories, especially those concerning boiling drinking water, are widely used to reduce risks of infection from contaminants in the water supply. Since the effectiveness of boil water advisories (BWAs) depends on public compliance, monitoring the public response to such advisories is essential for protecting human health. However, assessments of public compliance with BWAs remain sparse. Thus, this study was aimed at investigating awareness and compliance among residents who had received BWAs in Baerum municipality in Norway.

Method: We conducted a cross-sectional study among 2764 residents who had received water advisories by SMS in the municipality of Baerum between January and September 2017. We analysed data from two focus group discussions and an online survey sent to all residents who had received an advisory. We conducted descriptive analyses and calculated odds ratios (OR) using logistic regression to identify associations of compliance and awareness with demographic characteristics.

Results: Of the 611 respondents, 67% reported that they had received a water advisory notification. Effective compliance rate with safe drinking water practices, either by storing clean drinking water or boiling tap water, after a water outage was 72% among those who remembered receiving a notification. Compliance with safe drinking water advisories was lower among men than women (OR 0.53, 95% CI 0.29-0.96), but was independent of age, education and household type. The main reason for respondents' non-compliance with safe water practices was that they perceived the water to be safe to drink after letting it flush through the tap until it became clear.

Conclusions: Awareness of advisories was suboptimal among residents who had received notifications, but compliance was high. The present study highlights the need to improve the distribution, phrasing and content of water advisory notifications to achieve greater awareness and compliance. Future studies should include hard-to-reach groups with adequate data collection approaches and examine the use of BWAs in a national context to inform future policies on BWAs.
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http://dx.doi.org/10.1186/s12889-019-7504-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716804PMC
August 2019

Sensible vaccination.

Tidsskr Nor Laegeforen 2019 08 19;139(11). Epub 2019 Aug 19.

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http://dx.doi.org/10.4045/tidsskr.19.0441DOI Listing
August 2019

Vaccination programme for adults.

Tidsskr Nor Laegeforen 2019 May 20;139(9). Epub 2019 May 20.

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http://dx.doi.org/10.4045/tidsskr.19.0281DOI Listing
May 2019

Immigrant screening for latent tuberculosis infection: numbers needed to test and treat, a Norwegian population-based cohort study.

BMJ Open 2019 01 17;9(1):e023412. Epub 2019 Jan 17.

Department of Tuberculosis, Blood-Borne and Sexually Transmitted Infections, Norwegian Institute of Public Health, Oslo, Norway.

Objectives: To estimate the number needed to screen (NNS) and the number needed to treat (NNT) to prevent one tuberculosis (TB) case in the Norwegian immigrant latent tuberculosis infection (LTBI) screening programme and to explore the effect of delay of LTBI treatment initiation.

Design: Population-based, prospective cohort study.

Participants: Immigrants to Norway.

Outcome: Incident TB.

Methods: We obtained aggregated data on immigration to Norway in 2008-2011 and used data from the Norwegian Surveillance System for Infectious Diseases to assess the number of TB cases arising in this cohort within 5 years after arrival. We calculated the average NNS and NNT for immigrants from the top 10 source countries for TB in Norway and by estimated TB incidence rates in source countries. We explored the sensitivity of these estimates with regard to test performance, treatment efficacy and treatment adherence using an extreme value approach, and assessed the effects of emigration, time to TB diagnosis (to define incident TB) and intervention timing.

Results: NNS and NNT were overall high, with substantial variation. NNT showed numerically stronger negative correlation with TB notification rate in Norway (-0.75 [95% CI -1.00 to -0.44]) than with the WHO incidence rate (IR) (-0.32 [95% CI -0.93 to 0.29]). NNT was affected substantially by emigration and the definition of incident TB. Estimates were lowest for Somali (NNS 99 [70-150], NNT 27 [19-41]) and highest for Thai immigrants (NNS 585 [413-887], NNT 111 [79-116]). Implementing LTBI treatment in immigrants sooner after arrival may improve the effectiveness of the programme.

Conclusion: Using TB notifications in Norway, rather than IR in source countries, would improve targeting of immigrants for LTBI management. However, the overall high NNT is a concern and challenges the scale-up of preventive LTBI treatment for significant public health impact. Better data are urgently needed to monitor and evaluate NNS and NNT in countries implementing LTBI screening.
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http://dx.doi.org/10.1136/bmjopen-2018-023412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340421PMC
January 2019

Pandemic vaccination strategies and influenza severe outcomes during the influenza A(H1N1)pdm09 pandemic and the post-pandemic influenza season: the Nordic experience.

Euro Surveill 2016 04;21(16)

Statens Serum Institut, Copenhagen, Denmark.

During the 2009/10 influenza A(H1N1)pdm09 pandemic, the five Nordic countries adopted different approaches to pandemic vaccination. We compared pandemic vaccination strategies and severe influenza outcomes, in seasons 2009/10 and 2010/11 in these countries with similar influenza surveillance systems. We calculated the cumulative pandemic vaccination coverage in 2009/10 and cumulative incidence rates of laboratory confirmed A(H1N1)pdm09 infections, intensive care unit (ICU) admissions and deaths in 2009/10 and 2010/11. We estimated incidence risk ratios (IRR) in a Poisson regression model to compare those indicators between Denmark and the other countries. The vaccination coverage was lower in Denmark (6.1%) compared with Finland (48.2%), Iceland (44.1%), Norway (41.3%) and Sweden (60.0%). In 2009/10 Denmark had a similar cumulative incidence of A(H1N1)pdm09 ICU admissions and deaths compared with the other countries. In 2010/11 Denmark had a significantly higher cumulative incidence of A(H1N1)pdm09 ICU admissions (IRR: 2.4; 95% confidence interval (CI): 1.9-3.0) and deaths (IRR: 8.3; 95% CI: 5.1-13.5). Compared with Denmark, the other countries had higher pandemic vaccination coverage and experienced less A(H1N1)pdm09-related severe outcomes in 2010/11. Pandemic vaccination may have had an impact on severe influenza outcomes in the post-pandemic season. Surveillance of severe outcomes may be used to compare the impact of influenza between seasons and support different vaccination strategies.
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http://dx.doi.org/10.2807/1560-7917.ES.2016.21.16.30208DOI Listing
April 2016

Screening for Mycoplasma genitalium infection?

Tidsskr Nor Laegeforen 2016 Jan 26;136(2):104. Epub 2016 Jan 26.

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http://dx.doi.org/10.4045/tidsskr.16.0038DOI Listing
January 2016

The quality of denominator data in surgical site infection surveillance versus administrative data in Norway 2005-2010.

BMC Infect Dis 2015 Nov 30;15:549. Epub 2015 Nov 30.

Faculty of Health Sciences, Department of Community Medicine, Research Group Epidemiology of Chronic Diseases, UiT The Arctic University of Norway, Tromsø, Norway.

Background: High quality of surveillance systems for surgical site infections (SSIs) is the key to their usefulness. The Norwegian Surveillance System for Antibiotic Consumption and Healthcare-Associated Infections (NOIS) was introduced by regulation in 2005, and is based largely on automated extraction of data from underlying systems in the hospitals.

Methods: This study investigates the quality of NOIS-SSI's denominator data by evaluating completeness, representativeness and accuracy compared with de-identified administrative data for 2005-2010. Comparisons were made by region, hospital type and size, age and sex for 4 surgical procedures.

Results: The completeness of NOIS improved from 29.2 % in 2005 to 79.8 % in 2010. NOIS-SSI became representative over time for most procedures by hospital size and type, but not by region. It was representative by age and sex for all years and procedures. Accuracy was good for all years and procedures by all explanatory variables.

Conclusions: A flexible and incremental implementation strategy has encouraged the development of computer-based surveillance systems in the hospitals which gives good accuracy, but the same strategy has adversely affected the completeness and representativeness of the denominator data. For the purpose of evaluating risk factors and implementing prevention and precautionary measures in the individual hospitals, representativeness seems sufficient, but for benchmarking and/or public reporting it is not good enough.
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http://dx.doi.org/10.1186/s12879-015-1289-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4666046PMC
November 2015

Denominators count: supplementing surveillance data for genital Chlamydia trachomatis infection with testing data, Norway, 2007 to 2013.

Euro Surveill 2015 ;20(36)

Norwegian Institute of Public Health, Department of Infectious Disease Epidemiology, Oslo, Norway.

As genital Chlamydia trachomatis (chlamydia) infection is often asymptomatic, surveillance of diagnosed cases is heavily influenced by the rate and distribution of testing. In 2007, we started supplementing case-based surveillance data from the Norwegian Surveillance System for Communicable Diseases (MSIS) with aggregated data on age group and sex of individuals tested. In this report, annual testing rates, diagnosis rates and proportion positive for chlamydia in Norway between 1990 and 2013 are presented. From 2007, rates are also stratified by age group and sex. The annual testing rate for chlamydia culminated in the early 1990s, with 8,035 tested per 100,000 population in 1991. It then declined to 5,312 per 100,000 in 2000 after which it remained relatively stable. Between 1990 and 2013 the annual rate of diagnosed cases increased 1.5 times from ca 300 to ca 450 per 100,000 population. The proportion of positive among the tested rose twofold from ca 4% in the 1990s to 8% in 2013. Data from 2007 to 2013 indicate that more women than men were tested (ratio: 2.56; 95% confidence interval (CI): 2.56-2.58) and diagnosed (1.54; 95% CI: 1.52-1.56). Among tested individuals above 14 years-old, the proportion positive was higher in men than women for all age groups. Too many tests are performed in women aged 30 years and older, where 49 of 50 tests are negative. Testing coverage is low (15%) among 15 to 24 year-old males. Information on sex and age-distribution among the tested helps to interpret surveillance data and provides indications on how to improve targeting of testing for chlamydia. Regular prevalence surveys may address remaining limitations of surveillance.
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http://dx.doi.org/10.2807/1560-7917.ES.2015.20.36.30012DOI Listing
March 2016

Response to letter to the editor regarding: "Surgical site infections after hip arthroplasty in Norway, 2005-2011: Influence of duration and intensity of postdischarge surveillance".

Am J Infect Control 2015 09 29;43(9):1024-5. Epub 2015 Jul 29.

Faculty of Health Sciences, Department of Community Medicine, Research Group Epidemiology of Chronic Diseases, UiT The Arctic University of Norway, Tromsø, Norway.

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http://dx.doi.org/10.1016/j.ajic.2015.06.011DOI Listing
September 2015

Surgical site infections after hip arthroplasty in Norway, 2005-2011: influence of duration and intensity of postdischarge surveillance.

Am J Infect Control 2015 Apr 8;43(4):323-8. Epub 2015 Feb 8.

Faculty of Health Sciences, Department of Community Medicine, Research Group Epidemiology of Chronic Diseases, UiT The Arctic University of Norway, Tromsø, Norway.

Background: Most surgical site infections (SSIs) after hip arthroplasty are detected after a patient is discharged from hospital, making postdischarge surveillance (PDS) an important component in surveillance systems. We investigated how long it was necessary to monitor hip arthroplasty patients for SSIs after hospital discharge and if passive PDS through readmissions could replace active PDS by patient questionnaire in detecting SSIs.

Methods: We used data from the Norwegian surveillance system from 2005-2011, which has active 1-year PDS, to investigate proportions of SSIs found at different time intervals after surgery and whether these SSIs could have been detected through passive PDS by investigating the proportion of patients with SSIs that were readmitted.

Results: We found that 79% of all SSIs and 82% of deep SSIs were detected after hospital discharge. 95% of deep SSIs were detected within 90 days after surgery. 14% of the deep SSIs were detected beyond 30 days after surgery, and all of these patients were readmitted because of their SSI and thus could have been detected by passive PDS.

Conclusions: Our data suggest that most deep SSIs are detected within 90 days and that passive PDS beyond 30 days after surgery may replace active PDS without reducing sensitivity.
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http://dx.doi.org/10.1016/j.ajic.2014.12.013DOI Listing
April 2015

Implications of screening and childcare exclusion policies for children with Shiga-toxin producing Escherichia coli infections: lessons learned from an outbreak in a daycare centre, Norway, 2012.

BMC Infect Dis 2014 Dec 18;14:673. Epub 2014 Dec 18.

Department of Infectious Disease Epidemiology, Norwegian Institute of Public Health, P.O. Box 4404, Nydalen, NO-0403, Oslo, Norway.

Background: In Norway, it is recommended that children with Shiga-Toxin producing Escherichia coli (STEC) infections are excluded from daycare centers until up to five consecutive negative stool cultures are obtained. Children with gastrointestinal illness of unknown etiology are asked to remain home for 48 hours after symptoms subside. On 16 October 2012, two cases of STEC infection were reported from a daycare center, where other children were also symptomatic. Local health authorities temporarily closed the daycare center and all children and staff were screened for pathogenic E. coli. We present the results of the outbreak investigation in order to discuss the implications of screening and the exclusion policies for children attending daycare in Norway.

Methods: Stool specimens for all children (n = 91) and employees at the daycare center (n = 40) were tested for pathogenic E. coli. Information on demographics, symptoms and potential exposures was collected from parents through trawling interviews and a web-based questionnaire. Cases were monitored to determine the duration of shedding and the resulting exclusion period from daycare.

Results: We identified five children with stx1- and eae-positive STEC O103:H2 infections, and one staff member and one child with STEC O91:H- infections. Three additional children who tested positive for stx1 and eae genes were considered probable STEC cases. Three cases were asymptomatic. Median length of time of exclusion from daycare for STEC cases was 53 days (range 9 days-108 days). Survey responses for 75 children revealed mild gastrointestinal symptoms among both children with STEC infections and children with negative microbiological results. There was no evidence of common exposures; person-to-person transmission was likely.

Conclusions: The results of screening indicate that E. coli infections can spread in daycare centres, reflected in the proportion of children with STEC and EPEC infections. While screening can identify asymptomatic cases, the implications should be carefully considered as it can produce unanticipated results and have significant socioeconomic consequences. Daycare exclusion policies should be reviewed to address the management of prolonged asymptomatic shedders.
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http://dx.doi.org/10.1186/s12879-014-0673-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4279589PMC
December 2014

Counting pandemic deaths: comparing reported numbers of deaths from influenza A(H1N1)pdm09 with estimated excess mortality.

Influenza Other Respir Viruses 2013 Nov 8;7(6):1370-9. Epub 2013 Jun 8.

Department of Infectious Disease Epidemiology, Norwegian Institute of Public Health, Oslo, Norway; Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.

Background: During the wave 1 of the influenza A(H1N1)pdm09 virus, Norway appeared to be suffering from high mortality rates. However, by the end of the pandemic, it was widely reported that the number of deaths were much lower than previous years.

Objectives: The mortality burden from influenza is often assessed by two different approaches: counting influenza-certified deaths and estimating the mortality burden using models. The purpose of this study is to compare the number of reported deaths with results from two different models for estimating excess mortality during the pandemic in Norway. Additionally, mortality estimates for the pandemic season are compared with non-pandemic influenza seasons.

Methods: Numbers on reported influenza A(N1h1)pdm09 deaths are gived by the Cause of Death Registry at Statistics Norway and an ad hoc registry at the Norwegian Institute of Public Health. Overall and Pnemumonia and Influenza certified mortality is modeled using Poission regression, adjusting for levels of reported influenza-like illness and seasonal and year-to-year variation.

Results And Conclusions: Modelling results suggest that the excess mortality in older age groups is considerably lower during the pandemic than non-pandemic seasons, but there are indications of an excess beyond what was reported during the pandemic. This highlights the benefits of both methods and the importance of explaining where these numbers come from.
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http://dx.doi.org/10.1111/irv.12125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634244PMC
November 2013

Trends in HIV infection surveillance data among men who have sex with men in Norway, 1995-2011.

BMC Public Health 2013 Feb 17;13:144. Epub 2013 Feb 17.

Norwegian Institute of Public Health, Oslo, Norway.

Background: Recent reports on the growing HIV epidemic among men who have sex with men (MSM) in the EU/EEA area were accompanied by an increase of reported HIV among MSM in Oslo, Norway in 2003. Our study with data from 1995 to 2011 has described the recent trends of HIV among MSM in Norway and their socio-demographic and epidemiological characteristics.

Methods: The data were collected from the Norwegian Surveillance System for Communicable Diseases. Cases were described by age, place of infection, clinical presentation of HIV infection, STI co-infection and source partner. We used simple linear regression to estimate trends over time.

Results: During the study period, 991 MSM, aged from 16 to 80 years, were newly diagnosed with HIV. No significant trends over time in overall median age (36 years) were observed. Most of the MSM (505, 51%) were infected in Oslo. In the years 1995-2002, 30 to 45 MSM were diagnosed with HIV each year, while in the years 2003-2011 this increased to between 56 and 97 cases. The proportion of MSM, presenting with either AIDS or HIV illness, decreased over time, while asymptomatic and acute HIV illness increased (p for trend=0.034 or less). STI co-infection was reported in 133 (13%) cases. An overall increase of syphilis co-infected cases was observed (p for trend <0.001). A casual partner was a source of infection in 590 cases (60%).

Conclusions: Though the increases described could be attributed to earlier testing and diagnosis, no change in the median age of cases was observed. This indicates that it is likely that there has been an increase in HIV infections among MSM in Norway since 2003. The simultaneous increase in STI co-infections indicates risky sexual behaviour and a potential to spread both HIV and other sexually transmitted infections.
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http://dx.doi.org/10.1186/1471-2458-13-144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3585925PMC
February 2013

Systematic screening with information and home sampling for genital Chlamydia trachomatis infections in young men and women in Norway: a randomized controlled trial.

BMC Infect Dis 2013 Jan 23;13:30. Epub 2013 Jan 23.

Norwegian Institute of Public Health, Nydalen, Oslo, Norway.

Background: As most genital Chlamydia trachomatis infections are asymptomatic, many patients do not seek health care for testing. Infections remain undiagnosed and untreated. We studied whether screening with information and home sampling resulted in more young people getting tested, diagnosed and treated for chlamydia in the three months following the intervention compared to the current strategy of testing in the health care system.

Method: We conducted a population based randomized controlled trial among all persons aged 18-25 years in one Norwegian county (41 519 persons). 10 000 persons (intervention) received an invitation by mail with chlamydia information and a mail-back urine sampling kit. 31 519 persons received no intervention and continued with usual care (control). All samples from both groups were analysed in the same laboratory. Information on treatment was obtained from the Norwegian Prescription Database (NorPD). We estimated risk ratios and risk differences of being tested, diagnosed and treated in the intervention group compared to the control group.

Results: In the intervention group 16.5% got tested and in the control group 3.4%, risk ratio 4.9 (95% CI 4.5-5.2). The intervention led to 2.6 (95% CI 2.0-3.4) times as many individuals being diagnosed and 2.5 (95% CI 1.9-3.4) times as many individuals receiving treatment for chlamydia compared to no intervention in the three months following the intervention.

Conclusion: In Norway, systematic screening with information and home sampling results in more young people being tested, diagnosed and treated for chlamydia in the three months following the intervention than the current strategy of testing in the health care system. However, the study has not established that the intervention will reduce the chlamydia prevalence or the risk of complications from chlamydia.
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http://dx.doi.org/10.1186/1471-2334-13-30DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3558461PMC
January 2013

Risk of fetal death after pandemic influenza virus infection or vaccination.

N Engl J Med 2013 Jan 16;368(4):333-40. Epub 2013 Jan 16.

Norwegian Institute of Public Health, Oslo, Norway.

Background: During the 2009 influenza A (H1N1) pandemic, pregnant women were at risk for severe influenza illness. This concern was complicated by questions about vaccine safety in pregnant women that were raised by anecdotal reports of fetal deaths after vaccination.

Methods: We explored the safety of influenza vaccination of pregnant women by linking Norwegian national registries and medical consultation data to determine influenza diagnosis, vaccination status, birth outcomes, and background information for pregnant women before, during, and after the pandemic. We used Cox regression models to estimate hazard ratios for fetal death, with the gestational day as the time metric and vaccination and pandemic exposure as time-dependent exposure variables.

Results: There were 117,347 eligible pregnancies in Norway from 2009 through 2010. Fetal mortality was 4.9 deaths per 1000 births. During the pandemic, 54% of pregnant women in their second or third trimester were vaccinated. Vaccination during pregnancy substantially reduced the risk of an influenza diagnosis (adjusted hazard ratio, 0.30; 95% confidence interval [CI], 0.25 to 0.34). Among pregnant women with a clinical diagnosis of influenza, the risk of fetal death was increased (adjusted hazard ratio, 1.91; 95% CI, 1.07 to 3.41). The risk of fetal death was reduced with vaccination during pregnancy, although this reduction was not significant (adjusted hazard ratio, 0.88; 95% CI, 0.66 to 1.17).

Conclusions: Pandemic influenza virus infection in pregnancy was associated with an increased risk of fetal death. Vaccination during pregnancy reduced the risk of an influenza diagnosis. Vaccination itself was not associated with increased fetal mortality and may have reduced the risk of influenza-related fetal death during the pandemic. (Funded by the Norwegian Institute of Public Health.).
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http://dx.doi.org/10.1056/NEJMoa1207210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3602844PMC
January 2013

Methodology of the Norwegian Surveillance System for Healthcare-Associated Infections: the value of a mandatory system, automated data collection, and active postdischarge surveillance.

Am J Infect Control 2013 Jul 11;41(7):591-6. Epub 2013 Jan 11.

Norwegian Institute of Public Health, Oslo, Norway.

Background: Surveillance is a primary component of systems for the prevention of health care-associated infections (HCAI). Feedback to surgeons from these surveillance systems may reduce rates of surgical site infections (SSIs) by approximately 20%.

Objective: Our objective was to describe the Norwegian Surveillance System for Healthcare-Associated Infections' (NOIS) module for SSI (NOIS-SSI) and to evaluate the completeness of hospital participation, the effectiveness of automated data collection, and the added value of follow-up after hospital discharge during 2005 to 2009.

Methods: NOIS was introduced by regulation in 2005. Hospital participation is described through adherence to the mandatory requirements and participation in the voluntary aspects of the system. Automated data collection is evaluated through the completeness of reporting of explanatory and administrative variables. The impact of active postdischarge surveillance is assessed through the completeness of follow-up and the proportion of infections detected after hospital discharge.

Results: The system has achieved 95% (52/55) hospital participation, with 65% (34/52) of the hospitals submitting more data than the required minimum. The completeness of patient and procedure-related background data is satisfactory, with 23.3% (5,079/21,772) of the records having at least 1 missing value. The completeness of 30-day follow-up of patients is 90.7% (19,747/21,772), and 81% (765/948) of the infections were detected after discharge from hospital.

Conclusion: Implementation of a new surveillance system for SSI has been successful evaluated through hospital participation, the completeness of reporting of explanatory and administrative variables, and the completeness of postdischarge follow-up. Important success factors are a mandatory system, automated data-harvesting systems in hospitals, and active postdischarge surveillance.
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http://dx.doi.org/10.1016/j.ajic.2012.09.005DOI Listing
July 2013

Population based study of genital Chlamydia trachomatis prevalence and associated factors in Norway: a cross sectional study.

BMC Infect Dis 2012 Jul 2;12:150. Epub 2012 Jul 2.

Norwegian Institute of Public Health, Oslo, Norway.

Background: The number of diagnosed cases of Chlamydia trachomatis infection has been increasing in the past years in Norway although the testing rate has been relatively stable. The aim of this study was to measure the prevalence of genital Chlamydia trachomatis in young men and women in one county in Norway and determine associated factors in order to better target preventive measures.

Methods: We mailed to a random sample of 10,000 persons aged 18-25 in Rogaland county a mail-back urine sample kit and a self-administered questionnaire with questions on socio-demographic details, health seeking behaviour and symptoms of and history of sexually transmitted diseases. Associations between current Clamydia trachomatis infection and the above mentioned factors were studied by multiple logistic regression.

Results: The response rate among women was 18.9% (930/4923) and 11.9% (605/5077) among men. The prevalence of Chlamydia trachomatis infection was 5.8% (95% CI 4.5-6.8) among women and 5.1% (95% CI 3.8-6.8) among men. For men a greater number of partners during the last year (p for trend < 0.001), and living in a municipality without a local youth clinic increased the odds of infection (OR 8.6, 95% CI 2.2-33.9). For women a greater number of partners during the last year (p < 0.001) and not having consulted a family doctor for STIs (OR 2.1 95% CI 1.1-4.2) were positively associated with infection while not having a previous Chlamydia trachomatis diagnosis decreased the odds of having this infection (OR 0.3, 95% CI 0.2-0.7).

Conclusion: Our results indicate the importance of having a visible youth clinic in each municipality. It also suggests targeting women who have had a previous Chlamydia trachomatis infection diagnosed before.
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http://dx.doi.org/10.1186/1471-2334-12-150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3409045PMC
July 2012

Usefulness of health registries when estimating vaccine effectiveness during the influenza A(H1N1)pdm09 pandemic in Norway.

BMC Infect Dis 2012 Mar 20;12:63. Epub 2012 Mar 20.

Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway.

Background: During the 2009-2010 pandemic in Norway, 12 513 laboratory-confirmed cases of pandemic influenza A(H1N1)pdm09, were reported to the Norwegian Surveillance System for Communicable Diseases (MSIS). 2.2 million persons (45% of the population) were vaccinated with an AS03-adjuvanted monovalent vaccine during the pandemic. Most of them were registered in the Norwegian Immunisation Registry (SYSVAK). Based on these registries, we aimed at estimating the vaccine effectiveness (VE) and describing vaccine failures during the pandemic in Norway, in order to evaluate the role of the vaccine as a preventive measure during the pandemic.

Methods: We conducted a population-based retrospective cohort study, linking MSIS and SYSVAK with pandemic influenza vaccination as exposure and laboratory-confirmed pandemic influenza as outcome. We measured VE by week and defined two thresholds for immunity; eight and 15 days after vaccination.

Results: The weekly VE ranged from 77% to 96% when considering 15 days or more after vaccination as the threshold of immunity and from 73% to 94% when considering eight days or more. Overall, 157 individuals contracted pandemic influenza eight or more days after vaccination (8.4/100,000 vaccinated), of these 58 had onset 15 days or more after vaccination (3.0/100,000 vaccinated). Most of the vaccine failures occurred during the first weeks of the vaccination campaign. More than 30% of the vaccine failures were found in people below 10 years of age.

Conclusions: Having available health registries with data regarding cases of specific disease and vaccination makes it feasible to estimate VE in a simple and rapid way. VE was high regardless the immunity threshold chosen. We encourage public health authorities in other countries to set up such registries. It is also important to consider including information on underlying diseases in registries already existing, in order to make it feasible to conduct more complete VE estimations.
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http://dx.doi.org/10.1186/1471-2334-12-63DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3344681PMC
March 2012

Evaluation of the national surveillance system for point-prevalence of healthcare-associated infections in hospitals and in long-term care facilities for elderly in Norway, 2002-2008.

BMC Public Health 2011 Dec 13;11:923. Epub 2011 Dec 13.

Dept, of Hospital Epidemiology and Hygiene, National Center for Epidemiology, Budapest, Hungary.

Background: Since 2002, the Norwegian Institute of Public Health has invited all hospitals and long-term care facilities for elderly (LTCFs) to participate in two annual point-prevalence surveys covering the most frequent types of healthcare-associated infections (HAIs). In a comprehensive evaluation we assessed how well the system operates to meet its objectives.

Methods: Surveillance protocols and the national database were reviewed. Data managers at national level, infection control practitioners and ward personnel in hospitals as well as contact persons in LTCFs involved in prevalence data collection were surveyed.

Results: The evaluation showed that the system was structurally simple, flexible and accepted by the key partners. On average 87% of hospitals and 32% of LTCFs participated in 2004-2008; high level of data completeness was achieved. The data collected described trends in the prevalence of reportable HAIs in Norway and informed policy makers. Local results were used in hospitals to implement targeted infection control measures and to argue for more resources to a greater extent than in LTCFs. Both the use of simplified Centers for Disease Control and Prevention (CDC) definitions and validity of data seemed problematic as compliance with the standard methodology were reportedly low.

Conclusions: The surveillance system provides important information on selected HAIs in Norway. The system is overall functional and well-established in hospitals, however, requires active promotion in LTCFs. Validity of data needs to be controlled in the participating institutions before reporting to the national level.
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http://dx.doi.org/10.1186/1471-2458-11-923DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265568PMC
December 2011

Detection of events of public health importance under the international health regulations: a toolkit to improve reporting of unusual events by frontline healthcare workers.

BMC Public Health 2011 Sep 21;11:713. Epub 2011 Sep 21.

Department of Infectious Diseases Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.

Background: The International Health Regulations (IHR (2005)) require countries to notify WHO of any event which may constitute a public health emergency of international concern. This notification relies on reports of events occurring at the local level reaching the national public health authorities. By June 2012 WHO member states are expected to have implemented the capacity to "detect events involving disease or death above expected levels for the particular time and place" on the local level and report essential information to the appropriate level of public health authority. Our objective was to develop tools to assist European countries improve the reporting of unusual events of public health significance from frontline healthcare workers to public health authorities.

Methods: We investigated obstacles and incentives to event reporting through a systematic literature review and expert consultations with national public health officials from various European countries. Multi-day expert meetings and qualitative interviews were used to gather experiences and examples of public health event reporting. Feedback on specific components of the toolkit was collected from healthcare workers and public health officials throughout the design process.

Results: Evidence from 79 scientific publications, two multi-day expert meetings and seven qualitative interviews stressed the need to clarify concepts and expectations around event reporting in European countries between the frontline and public health authorities. An analytical framework based on three priority areas for improved event reporting (professional engagement, communication and infrastructure) was developed and guided the development of the various tools. We developed a toolkit adaptable to country-specific needs that includes a guidance document for IHR National Focal Points and nine tool templates targeted at clinicians and laboratory staff: five awareness campaign tools, three education and training tools, and an implementation plan. The toolkit emphasizes what to report, the reporting process and the need for follow-up, supported by real examples.

Conclusion: This toolkit addresses the importance of mutual exchange of information between frontline healthcare workers and public health authorities. It may potentially increase frontline healthcare workers' awareness of their role in the detection of events of public health concern, improve communication channels and contribute to creating an enabling environment for event reporting. However, the effectiveness of the toolkit will depend on the national body responsible for dissemination and training.
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http://dx.doi.org/10.1186/1471-2458-11-713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3188493PMC
September 2011