The state of integrated disease surveillance globally: synthesis report of a mixed methods study.

OBJECTIVES: Disease surveillance is an essential public health function needed to prevent, detect, monitor and respond to health threats. Integrated disease surveillance (IDS) enhances its utility and has been advocated for decades by the World Health Organization. This study sought to examine the state of IDS implementation worldwide. STUDY DESIGN: The study used a concurrent mixed methods approach consisting of a systematic scoping review of the literature on IDS, a survey of International Association of National Public Health Institutes (IANPHI) members and qualitative deep dive case studies in seven countries. METHODS: This report collates, analyses and synthesises the findings from the three components. The scoping review consisted of a review of summarised evidence on IDS. Eight reviews and five primary studies were included. The cross-sectional survey was conducted of 110 IANPHI members representing ninety-five countries. Qualitative case studies were conducted in Malawi, Mozambique, Uganda, Pakistan, Canada, Sweden, and England, which involved thirty-four focus group discussions and forty-eight key informant interviews. RESULTS: In the different countries, IDS is conceptualised differently and there are differing levels of maturity of IDS functions. Although the role of National Public Health Institutes has not been well defined in the IDS, they play a significant role in IDS in many countries. Fragmentation between sectors and resourcing (human and financial) issues were common. Good governance measures such as appropriate legislative and regulatory frameworks and roles and responsibilities for IDS were often unclear. The COVID-19 pandemic has strengthened some surveillance systems, often through leveraging existing respiratory surveillance systems. In some instances, improvements were seen only for COVID-19 related data but these changes were not sustained. Evaluation of IDS was also reported to be weak. CONCLUSIONS: Integration should be driven by a clear purpose and contextualised. Political commitment, clear governance, and resourcing are needed. Technology and the establishment of technical communities of practice may help. However, the complexity and cost of integration should not be under-estimated, and further economic and impact evaluations of IDS are needed.

Does integration with national registers improve the data completeness of local COVID-19 contact tracing tools? A register-based study in Norway, May 2020 - September 2021.

BACKGROUND: During the COVID-19 response in Norway, many municipalities used the Fiks contact tracing tool (FiksCT) to register positive individuals and follow-up contacts. This tool is based on DHIS2, an open source, web-based platform. In this study we examined if data completeness in FiksCT improved after integration with national registers between May 2020 and September 2021. METHODS: Data from municipalities using FiksCT was extracted from the Norwegian Emergency Preparedness Register for COVID-19 (Beredt C19). We linked FiksCT data to the Norwegian Surveillance System for Communicable Diseases (MSIS), the National Population Register (FREG), and the Norwegian Vaccine Registry (SYSVAK) using unique identification numbers (ID). Completeness for each variable linked with a national register was calculated before and after integration with these registers. RESULTS: Of the 125 municipalities using FiksCT, 87 (69.6%) agreed to share and upload their data to Beredt C19. Data completeness for positive individuals improved after integration with national registers. After integration with FREG, the proportion of missing values decreased from 12.5 to 1.6% for ID, from 4.5 to 0.9% for sex, and from 1.2 to 0.4% for date of birth. Missing values for vaccine type decreased from 63.0 to 15.2% and 39.3-36.7% for first and second dose, respectively. In addition, direct reporting from FiksCT to MSIS increased the proportion of complete records in MSIS (on the selected variables) from 68.6% before to 77.0% after integration. CONCLUSION: The completeness of local contact tracing data can be improved by enabling integration with established national registers. In addition, providing the option to submit local data to the national registers could ease workload and reduce the need to collect duplicate data.

Pseudomonas aeruginosa countrywide outbreak in hospitals linked to pre-moistened non-sterile washcloths, Norway, October 2021 to April 2022.

In November 2021, a clonal outbreak of Pseudomonas aeruginosa of novel sequence type ST3875 was detected in three patients who died of bloodstream infections in one hospital. By 25 April 2022, the outbreak included 339 cases from 38 hospitals across Norway. Initial hospital reports indicate Pseudomonas infection as the main contributing cause in seven deaths. In March 2022, the outbreak strain was identified in non-sterile pre-moistened disposable washcloths, used to clean patients, from three lots from the same international manufacturer.

Health communication in and out of public health emergencies: to persuade or to inform?

Much health communication during the COVID-19 pandemic has been designed to persuade people more than to inform them. For example, messages like "masks save lives" are intended to compel people to wear face masks, not to enable them to make an informed decision about whether to wear a face mask or to understand the justification for a mask mandate. Both persuading people and informing them are reasonable goals for health communication. However, those goals can sometimes be in conflict. In this article, we discuss potential conflicts between seeking to persuade or to inform people, the use of spin to persuade people, the ethics of persuasion, and implications for health communication in the context of the pandemic and generally. Decisions to persuade people rather than enable them to make an informed choice may be justified, but the basis for those decisions should be transparent and the evidence should not be distorted. We suggest nine principles to guide decisions by health authorities about whether to try to persuade people.

Improving National Intelligence for Public Health Preparedness: a methodological approach to finding local multi-sector indicators for health security.

The COVID-19 epidemic is the latest evidence of critical gaps in our collective ability to monitor country-level preparedness for health emergencies. The global frameworks that exist to strengthen core public health capacities lack coverage of several preparedness domains and do not provide mechanisms to interface with local intelligence. We designed and piloted a process, in collaboration with three National Public Health Institutes (NPHIs) in Ethiopia, Nigeria and Pakistan, to identify potential preparedness indicators that exist in a myriad of frameworks and tools in varying local institutions. Following a desk-based systematic search and expert consultations, indicators were extracted from existing national and subnational health security-relevant frameworks and prioritised in a multi-stakeholder two-round Delphi process. Eighty-six indicators in Ethiopia, 87 indicators in Nigeria and 51 indicators in Pakistan were assessed to be valid, relevant and feasible. From these, 14-16 indicators were prioritised in each of the three countries for consideration in monitoring and evaluation tools. Priority indicators consistently included private sector metrics, subnational capacities, availability and capacity for electronic surveillance, measures of timeliness for routine reporting, data quality scores and data related to internally displaced persons and returnees. NPHIs play an increasingly central role in health security and must have access to data needed to identify and respond rapidly to public health threats. Collecting and collating local sources of information may prove essential to addressing gaps; it is a necessary step towards improving preparedness and strengthening international health regulations compliance.

Water usage in the Gaza Strip: recommendations from a literature review and consultations with experts.

Water quality in the Gaza Strip has been severely compromised due to increasing salinity, contamination with pollutants, and lack of adequate treatment options. To provide the population of the Gaza Strip with advice on how to mitigate health risks from water we developed recommendations on using water from different sources for different purposes (such as for consumption, hygiene, amenities, and irrigation) based on a literature review and consultation with experts. Specific advice was developed for several vulnerable groups, including infants, children, pregnant or lactating women, and elderly people. The recommendations are inherently limited, as it is unacceptable to recommend consuming water that is of substandard quality. However, pending long-term solutions, information can be targeted to vulnerable groups to ensure that exposure to the most harmful contaminants is avoided. The implementation of these recommendations may require information campaigns to assist the population in differentiating water from different sources for different uses.

The mortality in Gaza in July-September 2014: a retrospective chart-review study.

BACKGROUND: The majority of Gazans who were killed or injured in the 2014 Israel-Gaza war were civilians, and one-fourth of the population were internally displaced. As the Gaza Strip is a small territory, the whole population was exposed to the war and its effects on the health care system, supplies and infrastructure. Our aim was to assess the overall, sex and age-group mortality in Gaza for the period July-September 2014 that was not caused by war injuries, and the proportion of non-trauma deaths among adults that occurred outside hospital wards. A comparison was made with the mortality for the same period in 2013. METHOD: Date, sex, age, cause and place of each death that was not attributed to war-related physical trauma were collected from death notification forms or death records in Gaza hospitals for the period 01 July to 30 September 2014. The same information was extracted from the local death register for all deaths in the same period in 2013. RESULTS: The mean age at death was 52.4 years in 2014 and 49.7 in 2013, and about 50 % were older than 60 years in both years. The crude non-trauma death rates among adults were 11.6 per 10,000 population in 2014 and 11.3 in 2013, and the age standardised 13.2 and 12.4, respectively. Higher death rates in 2014 were observed among elderly and women. Cardiovascular disease was the most common cause of death among adults of both sexes, and infectious diseases caused less than 10 % in both periods. Three maternal deaths were observed in 2013 and six in 2014 (p = 0.17). The proportion of deaths that occurred in a hospital ward was 71.5 % in 2013 and 51.2 % in 2014. CONCLUSIONS: The mortality from communicable diseases was low in Gaza. We did not detect a higher overall background mortality in the 2014 period compared to 2013, but the observed age and sex distribution differed. The proportion of non-trauma deaths among adults that occurred in a hospital ward was markedly lower during the war. The living conditions and health care situation in Gaza point to the need for close monitoring of mortality.

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

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.

Effect of vaccines and antivirals during the major 2009 A(H1N1) pandemic wave in Norway--and the influence of vaccination timing.

To evaluate the impact of mass vaccination with adjuvanted vaccines (eventually 40% population coverage) and antivirals during the 2009 influenza pandemic in Norway, we fitted an age-structured SEIR model using data on vaccinations and sales of antivirals in 2009/10 in Norway to Norwegian ILI surveillance data from 5 October 2009 to 4 January 2010. We estimate a clinical attack rate of approximately 30% (28.7-29.8%), with highest disease rates among children 0-14 years (43-44%). Vaccination started in week 43 and came too late to have a strong influence on the pandemic in Norway. Our results indicate that the countermeasures prevented approximately 11-12% of potential cases relative to an unmitigated pandemic. Vaccination was found responsible for roughly 3 in 4 of the avoided infections. An estimated 50% reduction in the clinical attack rate would have resulted from vaccination alone, had the campaign started 6 weeks earlier. Had vaccination been prioritized for children first, the intervention should have commenced approximately 5 weeks earlier in order to achieve the same 50% reduction. In comparison, we estimate that a non-adjuvanted vaccination program should have started 8 weeks earlier to lower the clinical attack rate by 50%. In conclusion, vaccination timing was a critical factor in relation to the spread of the 2009 A(H1N1) influenza. Our results also corroborate the central role of children for the transmission of A(H1N1) pandemic influenza.

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.

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.

[Disease caused by the new influenza A(H1N1) virus]. / Sykdom forårsaket av nytt A(H1N1)-influensavirus.

BACKGROUND: A new A(H1N1) influenza virus was detected in April 2009. The virus is now causing a pandemic of influenza. The article presents an overview of symptoms, complications, vulnerable groups, diagnosis and treatment. MATERIAL AND METHODS: The overview is based on literature identified through a search in PubMed (using PubMed's own search strategy) and on official reports from WHO and the disease control centres of EU and the USA. RESULTS: The new influenza A(H1N1) has so far mainly affected young people, only few people over 60 years. The clinical presentation is similar to that of ordinary influenza; but nausea, vomiting and diarrhoea seem to be more common. The reported risk of complications and case fatality are low, but hospitalisation, pneumonia and deaths have occurred, also in previously healthy young individuals. Antiviral treatment with oseltamivir or zanamivir is likely to be as effective as in ordinary influenza. INTERPRETATION: Mild cases may be underrepresented in the published literature. It is important to keep up-to-date on international reports on the nature of the disease in order to best prepare clinicians to diagnose and treat patients when the epidemic hits Norway with full force.

Questions on causality and responsibility arising from an outbreak of Pseudomonas aeruginosa infections in Norway.

In 2002, Norway experienced a large outbreak of Pseudomonas aeruginosa infections in hospitals with 231 confirmed cases. This fuelled intense public and professional debates on what were the causes and who were responsible. In epidemiology, other sciences, in philosophy and in law there is a long tradition of discussing the concept of causality. We use this outbreak as a case; apply various theories of causality from different disciplines to discuss the roles and responsibilities of some of the parties involved. Mackie's concept of INUS conditions, Hill's nine viewpoints to study association for claiming causation, deterministic and probabilistic ways of reasoning, all shed light on the issues of causality in this outbreak. Moreover, applying legal theories of causation (counterfactual reasoning and the "but-for" test and the NESS test) proved especially useful, but the case also illustrated the weaknesses of the various theories of causation.We conclude that many factors contributed to causing the outbreak, but that contamination of a medical device in the production facility was the major necessary condition. The reuse of the medical device in hospitals contributed primarily to the size of the outbreak. The unintended error by its producer--and to a minor extent by the hospital practice--was mainly due to non-application of relevant knowledge and skills, and appears to constitute professional negligence. Due to criminal procedure laws and other factors outside the discourse of causality, no one was criminally charged for the outbreak which caused much suffering and shortening the life of at least 34 people.

Nationwide study of invasive Pseudomonas aeruginosa infection in Norway: importance of underlying disease.

OBJECTIVE: Pseudomonas aeruginosa is an opportunistic pathogen that may cause invasive disease. We describe the epidemiology of invasive P. aeruginosa infection in Norway and identify associated clinical factors. METHODS: All patients with invasive P. aeruginosa and Pseudomonas not identified at the species level (Pseudomonas spp.) in Norway 1992-2002 were included. Detailed information was collected for all cases during 1999-2002. Population and health institution statistics were obtained from national databases. RESULTS: In 1999-2002 the incidence rate was 3.16 per 100 000 person-years at risk or 0.20 per 1000 hospital stays. For hospital-acquired infection the rate was 671 per 100 000 person-years as compared with 1.13 for community-acquired infection, and 37 in nursing homes. The highest risk for invasive Pseudomonas disease was found in patients with malignant neoplasms of lymphoid and haematopoietic tissue (risk per 1000 hospital stays 1.9; 95% CI 1.5-2.3) and other diseases of blood and blood-forming organs (2.2; 95% CI 1.2-3.7). The case fatality rate was 35%. CONCLUSIONS: The incidence of invasive P. aeruginosa infection in this population-based study was much lower than in most single-hospital studies. The nationwide study design and prudent antibiotic use may explain some of the difference. Infection risk is strongly associated with certain underlying diseases.

[Should children adopted from abroad be screened for methicillin-resistant Staphylococcus aureus?]. / Bør barn adoptert fra utlandet undersøkes for meticillinresistente stafylokokker?

BACKGROUND: Patients with increased risk of colonisation with Methicillin-resistant Staphylococcus aureus (MRSA) are screened before admission to hospitals in Norway. Denmark and the Netherlands have introduced routine screening of all children adopted from abroad before hospital admission. The present study aims at identifying whether children adopted to Norway had a higher risk of being MRSA-positive than other children of the same age. METHODS: Incidence rates and relative risks for MRSA-infections or colonisation were calculated for children adopted from abroad and for other children. Data from Statistics Norway and the Norwegian Surveillance System for Communicable Diseases (MSIS) were used. RESULTS: The incidence rate for confirmed MRSA-infection in children < 3 years of age adopted from abroad was 1.1 per 1,000 person year, and that for other children was 0.034 per 1,000 person year in the period 1995-2005. In this period, adopted children had 33 times increased risk of being notified with MRSA-infection. In 2005, the incidence rate for detected colonisation with MRSA was 3.7/1,000 person year for adopted children and 0.053/1,000 person year for other children; i.e. in this year the risk of being found colonised with MRSA was 70 times higher for children adopted from abroad than for others. INTERPRETATION: Norwegian hospitals should introduce screening for MRSA at hospital admission as a routine for children adopted from abroad during the last 12 months. The National Institute of Public Health should continue to survey the incidence of MRSA among groups in the population and prospectively change the recommendations for MRSA-screening according to new knowledge.

Pseudomonas aeruginosa contamination of mouth swabs during production causing a major outbreak.

BACKGROUND: In 2002 we investigated an outbreak comprising 231 patients in Norway, caused by Pseudomonas aeruginosa and linked to the use of contaminated mouth swabs called Dent-O-Sept. Here we describe the extent of contamination of the swabs, and identify critical points in the production process that made the contamination possible, in order to prevent future outbreaks. METHODS: Environmental investigation with microbiological examination of production, ingredients and product, molecular typing of bacteria and a system audit of production. RESULTS: Of the 1565 swabs examined from 149 different production batches the outbreak strain of P. aeruginosa was detected in 76 swabs from 12 batches produced in 2001 and 2002. In total more than 250 swabs were contaminated with one or more microbial species. P. aeruginosa was detected from different spots along the production line. The audit revealed serious breeches of production regulations. Health care institutions reported non-proper use of the swabs and weaknesses in their purchasing systems. CONCLUSION: Biofilm formation in the wet part of the production is the most plausible explanation for the continuous contamination of the swabs with P. aeruginosa over a period of at least 30 weeks. When not abiding to production regulations fatal consequences for the users may ensue. For the most vulnerable patient groups only documented quality-controlled, high-level disinfected products and items should be used in the oropharynx.

An outbreak of Pseudomonas aeruginosa infection caused by contaminated mouth swabs.

BACKGROUND: Pseudomonas aeruginosa is an opportunistic bacterium that can cause severe infection in susceptible patients. During the winter of 2001-2002, we investigated an outbreak of P. aeruginosa infection among patients in several hospitals across Norway. METHODS: A nationwide outbreak investigation was performed with case finding, questionnaires, and product sampling. All available clinical and environmental P. aeruginosa strains were genotyped. Detailed information was collected from patients with the outbreak strain or with any P. aeruginosa in blood or cerebrospinal fluid samples. To identify risk factors, we conducted a case-control study among patients with P. aeruginosa isolated from blood or cerebrospinal fluid samples during October 2001-December 2002. Case patients were patients infected with the outbreak genotype, and control subjects were patients infected with other genotypes. RESULTS: A total of 231 patients from 24 hospitals were identified as having the outbreak strain; 39 of these patients had positive blood culture results. Seventy-one patients (31%) died while hospitalized; all of the patients who died had severe underlying disease. Among 39 case patients and 159 control subjects, use of the moist mouth swab (adjusted odds ratio, 5.3; 95% confidence interval, 2.0-13.6) and receipt of mechanical ventilation (adjusted odds ratio, 6.4; 95% confidence interval, 2.3-17.2) were associated with infection due to the outbreak strain. Genotypically identical strains of P. aeruginosa were identified in 76 mouth swabs from 12 different batches and from the production line. CONCLUSIONS: Contamination of mouth swabs during production caused the largest-ever outbreak of P. aeruginosa infection in Norway. Susceptible patient groups should use only documented quality-controlled, high-level-disinfected products and items in the oropharynx.

[Vaccination against influenza--why, for whom and with which vaccine?]. / Influensavaksinering--hvorfor, for hvem og med hvilken vaksine?

Every year, 5-10% of Norwegians become sick from influenza. Some groups, such as the elderly and the seriously ill, are at greater risk of contracting a serious form of influenza leading to complications and death. Annual influenza vaccination in such groups reduces the risk for pneumonia, hospitalisation and death. Vaccination of health care workers reduces the mortality rate among patients during the winter season. In Norway, around 900,000 persons belong to a group at risk and should be offered vaccination. In the winter of 2005/06, about 45% of these groups were vaccinated; the aim is 75% by 2010. Whether people get vaccinated or not depends much on their self-perceived need of vaccination. Health care workers play an important role in raising awareness of and spreading information about influenza and vaccination. Sending personal invitations and arranging mass vaccination days are effective in increasing the rate of vaccination.