Targeting TB or MRSA in Norwegian municipalities during 'the refugee crisis' of 2015: a framework for priority setting in screening.

IntroductionIn 2015, there was an increase in the number of asylum seekers arriving in Europe. Like in other countries, deciding screening priorities for tuberculosis (TB) and meticillin-resistant Staphylococcus aureus (MRSA) was a challenge. At least five of 428 municipalities chose to screen asylum seekers for MRSA before TB; the Norwegian Institute for Public Health advised against this.AimTo evaluate the MRSA/TB screening results from 2014 to 2016 and create a generalised framework for screening prioritisation in Norway through simulation modelling.MethodsThis is a register-based cohort study of asylum seekers using data from the Norwegian Surveillance System for Communicable Diseases from 2014 to 2016. We used survey data from municipalities that screened all asylum seekers for MRSA and denominator data from the Directorate of Immigration. A comparative risk assessment model was built to investigate the outcomes of prioritising between TB and MRSA in screening regimes.ResultsOf 46,090 asylum seekers, 137 (0.30%) were diagnosed with active TB (notification rate: 300/100,000 person-years). In the municipalities that screened all asylum seekers for MRSA, 13 of 1,768 (0.74%) were found to be infected with MRSA. The model estimated that screening for MRSA would prevent eight MRSA infections while prioritising TB screening would prevent 24 cases of active TB and one death.ConclusionOur findings support the decision to advise against screening for MRSA before TB among newly arrived asylum seekers. The model was an effective tool for comparing screening priorities and can be applied to other scenarios in other countries.

Treatment completion for latent tuberculosis infection in Norway: a prospective cohort study.

BACKGROUND: Successful treatment of latent tuberculosis infection (LTBI) is essential to reduce tuberculosis (TB) incidence rates in low-burden countries. This study measures treatment completion and determinants of non-completion of LTBI treatment in Norway in 2016. METHODS: This prospective cohort study included all individuals notified with LTBI treatment to the Norwegian Surveillance System for Infectious Diseases (MSIS) in 2016. We obtained data from MSIS and from a standardized form that was sent to health care providers at the time of patient notification to MSIS. We determined completion rates. Pearson's chi squared test was used to study associations between pairs of categorical variables and separate crude and multivariable logistic regression models were used to identify factors associated with treatment completion and adverse drug effects. RESULTS: We obtained information on treatment completion from 719 of the 726 individuals notified for LTBI treatment in 2016. Overall, 91% completed treatment. Treatment completion was highest in the foreign-born group [foreign-born, n = 562 (92%) vs Norwegian-born, n = 115 (85%), p = 0.007]. Treatment completion did not differ significantly between prescribed regimens (p = 0.124). Adverse events were the most common reason for incomplete treatment. We found no significant differences in adverse events when comparing weekly rifapentine (3RPH) with three months daily isoniazid and rifampicin (3RH). However, there were significantly fewer adverse events with 3RPH compared to other regimens (p = 0.037). Age over 35 years was significantly associated with adverse events irrespective of regimen (p = 0.024), whereas immunosuppression was not significantly associated with adverse events after adjusting for other variables (p = 0.306). Treatment under direct observation had a significant effect on treatment completion for foreign-born (multivariate Wald p-value = 0.017), but not for Norwegian-born (multivariate Wald p-value = 0.408) individuals. CONCLUSIONS: We report a very high treatment completion rate, especially among individuals from countries with high TB incidence. The follow-up from tuberculosis-coordinators and the frequent use of directly observed treatment probably contributes to this. Few severe adverse events were reported, even with increased age and in individuals that are more susceptible. While these results are promising, issues of cost-effectiveness and targeting treatment to individuals at highest risk of TB are important components of public health impact.

Tuberculosis outbreak in Eastern Norway.

BACKGROUND: Tuberculosis is a rare disease in Norway, especially among those who are born here. Contact tracing for cases of pulmonary tuberculosis is essential to find others who are ill or infected, and to prevent further infection. This article describes the investigation of an outbreak in which many of those infected or ill were Norwegian adolescents. MATERIAL AND METHOD: Nine persons directly or indirectly associated with the same educational institution were diagnosed with tuberculosis in 2013. Genetic testing of tuberculosis bacteria linked a further 13 cases of the disease reported in Eastern Norway during the period 2009-2013 to the outbreak. Information from the Norwegian Surveillance System for Communicable Diseases (MSIS) was used to investigate the outbreak, and information was also retrieved on exposure and contact networks. RESULTS: The first patient at the educational institution had long-term symptoms before diagnosis. Contact tracing for this case included 319 persons, of whom eight were ill, 49 infected and 37 received preventive therapy. The extent of contract tracing for the remaining 21 cases varied and included a total of 313 persons, of whom two were found to be ill (included in the 21 cases), 30 were infected and 12 received preventive therapy. INTERPRETATION: Delayed diagnosis led to an unusually large tuberculosis outbreak in a Norwegian context. The extent of contact tracing varied with no obvious relation to the infectiousness of the index patient. The outbreak demonstrates the importance of continued vigilance with regard to tuberculosis as a differential diagnosis, also among patients born in Norway.

[Use of coercion pursuant to the Communicable Diseases Act 1995-2013]. / Tvangstiltak etter smittevernloven 1995-2013.

BACKGROUND: The Communicable Diseases Act came into force in 1995. The Act authorises coercive examination and isolation of infected individuals. We wished to investigate how the provisions on coercion in this Act have been practised. MATERIAL AND METHOD: We reviewed all the cases that had been processed by the National Commission for Communicable Diseases from 1995 to the end of 2013. We contacted doctors in regional health enterprises to collect information on any emergency decisions having been made. We collected information from the tuberculosis register on treatment outcomes for tuberculosis, and investigated how many patients disappeared from treatment during 1995-2013. RESULTS: The communicable diseases commission had treated 15 cases involving a total of 12 individuals. Nine of these suffered from contagious pulmonary tuberculosis, one had primary tuberculosis, one was suspected of having tuberculosis and one was HIV positive. Three of the patients had multidrug-resistant tuberculosis. The commission made two decisions on coercive examination/brief isolation and nine on coercive isolation, as well as two decisions on extended isolation. No decisions were made regarding coercive treatment. Only four of the nine patients with contagious pulmonary tuberculosis completed the treatment sequence. One emergency decision has been made since 2006. INTERPRETATION: The provisions on coercion have been practised restrictively. Amendments to them should be considered, especially with regard to the opportunity to make emergency decisions on isolation of persons with a known diagnosis. There is a need for clearer regulations regarding extended isolation, and the time needed for processing of cases involving requests for a decision by the communicable diseases commission should be reduced.

The First GAEN-Based COVID-19 Contact Tracing App in Norway Identifies 80% of Close Contacts in "Real Life" Scenarios.

The coronavirus disease 2019 (COVID-19) response in most countries has relied on testing, isolation, contact tracing, and quarantine (TITQ), which is labor- and time-consuming. Therefore, several countries worldwide launched Bluetooth-based apps as supplementary tools. The aim of using contact tracing apps is to rapidly notify people about their possible exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and thus make the process of TITQ more efficient, especially upon exposure in public places. We evaluated the Norwegian Google Apple exposure notification (GAEN)-based contact tracing app Smittestopp v2 under relevant "real-life" test scenarios. We used a total of 40 devices, representing six different brands, and compared two different exposure configurations, experimented with different time thresholds and weights of the Bluetooth attenuation levels (buckets), and calculated the true notification rates among close contacts (≤2 m and ≥15 min) and false notification of sporadic contacts. In addition, we assessed the impact of using different operating systems and locations of the phone (hand/pocket). The best configuration tested to trigger exposure notification resulted in the correct notification of 80% of the true close contacts and incorrect notification of 34% of the sporadic contacts. Among those who incorrectly received notifications, most (67%) were within 2 m but the duration of contact was <15 min and thus they were not, per se, considered as "close contacts." Lower sensitivity was observed when using the iOS operating systems or carrying the phone in the pocket instead of in the hand. The results of this study were used to improve and evaluate the performance of the Norwegian contact-tracing app Smittestopp.

Immigrant screening for latent tuberculosis in Norway: a cost-effectiveness analysis.

The incidence of tuberculosis (TB) disease has increased in Norway since the mid-1990s. Immigrants are screened, and some are treated, for latent TB infection (LTBI) to prevent TB disease (reactivation). In this study, we estimated the costs of both treating and screening for LTBI and TB disease, which has not been done previously in Norway. We developed a model to indicate the cost-effectiveness of four different screening algorithms for LTBI using avoided TB disease cases as the health outcome. Further, we calculated the expected value of perfect information (EVPI), and indicated areas of LTBI screening that could be changed to improve cost-effectiveness. The costs of treating LTBI and TB disease were estimated to be €1938 and €15,489 per case, respectively. The model evaluates four algorithms, and suggests three cost-effective algorithms depending on the cost-effectiveness threshold. Screening all immigrants with interferon-gamma release assays (IGRA) requires the highest threshold (€28,400), followed by the algorithms "IGRA on immigrants with risk factors" and "no LTBI screening." EVPI is approximately €5 per screened immigrant. The costs for a cohort of 20,000 immigrants followed through 10 years range from €12.2 million for the algorithm "screening and treatment for TB disease but no LTBI screening," to €14 million for "screening all immigrants for both TB disease and LTBI with IGRA." The results suggest that the cost of TB disease screening and treatment is the largest contributor to total costs, while LTBI screening and treatment costs are relatively small. Increasing the proportion of IGRA-positive immigrants who are treated decreases the costs per avoided case substantially.