Non-heat-treated frozen raspberries the most likely vehicle of a norovirus outbreak in Oslo, Norway, November 2013.

In November 2013, the Norwegian Institute of Public Health was notified of a gastroenteritis outbreak following two meetings held at a conference centre. Identical food and beverages were served during the meetings. We investigated in order to identify the vehicle of infection and implement control measures. Meeting participants completed an online questionnaire on consumption of foods and beverages. We asked symptomatic participants to provide a stool sample. We defined a case as diarrhoea and/or vomiting in a participant who became ill within 3 days after the meeting. We calculated attack rates (AR) and adjusted risk ratios (aRR) with 95% confidence intervals (CI) using binomial regression. We conducted environmental investigations. Overall, 147/168 (88%) participants responded, of which 74 (50%) met the case definition. All five stool samples provided were norovirus positive. No kitchen staff reported being sick. Risk of illness was higher in those who consumed raspberry mousse (aRR 3·4, 95% CI 1·4-8·2) and sliced fresh fruit (aRR 1·9, 95% CI 1·3-2·8). Seventy cases (95%) ate raspberry mousse. Frozen raspberries used for the mousse were imported and not heat-treated before consumption. Non-heat-treated frozen raspberries were the most likely outbreak vehicle. Contamination by a food handler could not be excluded. We recommend heat-treatment of imported frozen berries before consumption.

Two cases of acute severe flaccid myelitis associated with enterovirus D68 infection in children, Norway, autumn 2014.

Enterovirus D68 (EV-D68), phylogenetic clade B was identified in nasopharyngeal specimens of two cases of severe acute flaccid myelitis. The cases were six and five years-old and occurred in September and November 2014. EV-D68 is increasingly associated with acute flaccid myelitis in children, most cases being reported in the United States. Awareness of this possible neurological complication of enterovirus D68 infection is needed.

Prescribing for off-label use and unauthorized medicines in three paediatric wards in Finland, the status before and after the European Union Paediatric Regulation.

WHAT IS KNOWN AND OBJECTIVE: The European Paediatric Regulation aims to reduce off-label use of medicines in paediatric pharmacotherapy. Prescribing for off-label use and unauthorized medicines was common in the paediatric wards of the Kuopio University Hospital in 2001. To evaluate the possible impact of the Regulation on the prevalence and the frequency on such prescribing, we repeated the study in 2011 as it was conducted 10 years earlier. METHODS: In this prospective study, the prescriptions for patients below 18 years of age were reviewed during a 2-week period in each of the three wards; neonatal intensive care unit, general paediatric ward and paediatric surgical ward in April and May 2011. The medicine's authorizing status of all prescriptions was determined according to the approved summary of product characteristics valid during the study in Finland. Data concerning unauthorized medicines were also recorded and classified. RESULTS: Out of the entire study population of 123 patients, 119 received a total of 1054 prescriptions in 2011. The proportion of patients with at least one prescription for off-label use or for an unauthorized medicine was significantly higher, 79% (n = 97) in 2011, compared to 58% in 2001 (P < 0·001). For newborns, significantly more prescriptions were for off-label use in 2011 than in 2001 (51% vs. 22%; P < 0·001). The proportion of prescriptions for unauthorized medicines was significantly higher in children below 2 years of age than in older children in both years (21% vs. 5% in 2011 and 24% vs. 3% in 2001, P < 0·001). WHAT IS NEW AND CONCLUSION: The prescribing for off-label use and unauthorized medicines was more prevalent in 2011 than in 2001. This indicates that the recent legislation has had only minor or no impact on the authorizing status of medicines commonly used in paediatric inpatients in specialized care.

Parental reporting of adverse drug events and other drug-related problems in children in Finland.

PURPOSE: Drug-related problems (DRPs) are common in paediatric pharmacotherapy, but few studies describe them from the parents' perspective. In the present survey, we have investigated the lifetime prevalence and type of DRPs in children in Finland. METHODS: This was a population-based survey of a random sample of 6,000 children below 12 years of age in 2007. A questionnaire was sent to their parents. The final response rate was 67% with a study population of 4,032. The main outcome measure was the lifetime prevalence and type of DRPs. RESULTS: The lifetime prevalence of DRPs was 21% (95% CI 20-22). The most common (82%) of the 1,346 reported DRPs were adverse drug events (ADEs). The prevalence of ADEs was 17% (95% CI 16-19), that of other DRPs 5.2% (95% CI 4.5-5.9). The prevalence of serious ADEs was 0.4% and that of unexpected ADEs was 0.8%. The most common system involved in the ADEs was the gastrointestinal tract, comprising 34% of the 1,106 ADEs. The most common of the 240 other DRPs were problems with the administration and dosing of medicine (86%). Overall, 64% of DRPs were related to anti-infectives. CONCLUSIONS: One fifth of the Finnish children below 12 years of age had experienced DRPs. Appropriate counselling, including possible adverse drug reactions and dosing directions, is important for parents and children at both the prescribing and dispensing of medicines for paediatric patients. Reporting of any suspected serious or unexpected ADEs is an essential part of efficient pharmacovigilance in paediatrics.

Measles virus genotyping an important tool in measles outbreak investigation in Norway, 2011.

This study describes 33 laboratory-confirmed cases of measles that occurred in Norway in 2011, mainly among unvaccinated children between seven months and 10 years of age. Laboratory testing included detection of anti-measles IgM- and IgG antibodies by enzyme-linked immunosorbent assay (ELISA) and molecular detection and characterisation of measles virus by polymerase chain reaction (PCR) and sequencing. Epidemiological data and genotyping revealed that the measles cases originated from eight separate importations, resulting in four outbreaks and four sporadic cases. Except for the first outbreak which affected 18 cases, limited secondary spread occurred in each of the three other outbreaks. The outbreaks were caused by measles virus genotypes B3, D4 and D9, whereas genotypes D8 and B3 were detected in the sporadic cases. This study highlights that genetic characterisation of measles virus is an essential tool in the laboratory surveillance of measles, especially in countries like Norway which are approaching the measles elimination goal. The investigation revealed that importation of measles resulted in subsequent transmission within Norway to non-vaccinated individuals, and twelve cases occurred in healthcare settings, involving both staff and children. The four cases detected among healthcare workers (HCWs) emphasised that the coverage of measles-mumps-rubella (MMR) vaccination among healthcare personnel needs to be improved and both primary and secondary vaccine failure was demonstrated in two fully immunised HCWs.

Ongoing outbreak of measles in Oslo, Norway, January-February 2011.

Between 19 January and 17 February 2011, 10 cases of measles (eight laboratory-confirmed and two probable) were reported in Oslo with the majority of cases in a mainly unvaccinated immigrant community. Of these, two cases were identified outside the immigrant community, in Norwegian children.

Fatal and mild primary dengue virus infections imported to Norway from Africa and south-east Asia, 2008-2010.

Between 2008 and 2010, eight cases of viraemic dengue fever in travellers were diagnosed in Norway. They had returned from Eritrea, Thailand and Indonesia. All cases were primary dengue infections, seven non-complicated dengue fever and one dengue shock syndrome with a fatal outcome. Four patients were infected with dengue virus serotype 1, one with type 2 and three with type 3. Two cases from Thailand, the fatal case and the two imported from Eritrea were infected with type 1.

Analysis of integrated virological and epidemiological reports of norovirus outbreaks collected within the Foodborne Viruses in Europe network from 1 July 2001 to 30 June 2006.

The Foodborne Viruses in Europe network has developed integrated epidemiological and virological outbreak reporting with aggregation and sharing of data through a joint database. We analyzed data from reported outbreaks of norovirus (NoV)-caused gastroenteritis from 13 European countries (July 2001 to July 2006) for trends in time and indications of different epidemiology of genotypes and variants. Of the 13 countries participating in this surveillance network, 11 were capable of collecting integrated epidemiological and virological surveillance data and 10 countries reported outbreaks throughout the entire period. Large differences in the numbers and rates of reported outbreaks per country were observed, reflecting the differences in the focus and coverage of national surveillance systems. GII.4 strains predominated throughout the 5-year surveillance period, but the proportion of outbreaks associated with GII.4 rose remarkably during years in which NoV activity was particularly high. Spring and summer peaks indicated the emergence of genetically distinct variants within GII.4 across Europe and were followed by increased NoV activity during the 2002-2003 and 2004-2005 winter seasons. GII.4 viruses predominated in health care settings and in person-to-person transmission. The consecutive emergence of new GII.4 variants is highly indicative of immune-driven selection. Their predominance in health care settings suggests properties that facilitate transmission in settings with a high concentration of people such as higher virus loads in excreta or a higher incidence of vomiting. Understanding the mechanisms driving the changes in epidemiology and clinical impact of these rapidly evolving RNA viruses is essential to design effective intervention and prevention measures.

Data quality of 5 years of central norovirus outbreak reporting in the European Network for food-borne viruses.

BACKGROUND: The food-borne viruses in Europe (FBVE) network database was established in 1999 to monitor trends in outbreaks of gastroenteritis due to noroviruses (NoVs), to identify major transmission routes of NoV infections within and between participating countries and to detect diffuse international food-borne outbreaks. METHODS: We reviewed the total of 9430 NoV outbreak reports from 13 countries with date of onset between 1 January 2002 and 1 January 2007 for representativeness, completeness and timeliness against these objectives. RESULTS: Rates of reporting ranged from a yearly average of 1.8 in 2003 to 11.6 in 2006. Completeness of reporting of an agreed minimum dataset improved over the years, both for epidemiological and virological data. For the 10 countries that provided integrated (epidemiological AND virological) reporting over the 5-year period, the completeness of the minimum dataset rose from 15% in 2003 to 48% in 2006. Two countries have not been able to combine both data types due to the structure of the national surveillance system (England and Wales and Germany). Timeliness of reporting (median days between the onset of an outbreak and the date of reporting to the FBVE database) differed greatly between countries, but gradually improved to 47 days in 2006. CONCLUSION: The outbreaks reported to the FBVE reflect the lack of standardization of surveillance systems across Europe, making direct comparison of data between countries difficult. However, trends in reported outbreaks per country, distribution of NoV genotypes, and detection of diffuse international outbreaks were used as background data in acute questions about NoV illness and the changing genotype distribution during the 5-year period, shown to be of added value. Integrated reporting is essential for these objectives, but could be limited to sentinel countries with surveillance systems that allow this integration. For successful intervention in case of diffuse international outbreaks, completeness and timeliness of reporting would need to be improved and expanded to countries that presently do not participate.

No sequence variation in part of the hexon and the fibre genes of adenovirus 8 isolated from patients with conjunctivitis or epidemic keratoconjunctivitis (EKC) in Norway during 1989 to 1996.

BACKGROUND/AIMS: Several local epidemics of keratoconjunctivitis/conjunctivitis caused by adenovirus type 8 (Ad8) occurred in Norway from August 1995 to May 1996. A smaller epidemic occurred in 1992. The Ad8 hexon forms the surface of the virion and contains the hypervariable regions loop I(1) and loop I(2). The fibre mediates the primary contact with cells. Sequence variation in hexon and fibre genes might play an important role in the pathogenicity of adenoviruses. The aim of this study was to investigate the genetic variability at the hexon and fibre genes in 26 strains of Ad8 isolated from 1989 to 1996. METHODS: The genetic variability of 26 strains of Ad8 isolated from 1989 to 1996 was studied by sequencing part of the hexon and fibre genes. The Ad8 sequences were compared with each other and with two Ad8 strains from the EMBL database. In addition, 14 of the 26 isolates were subjected to restriction endonuclease analysis. RESULTS: No significant sequence variation was seen during the six year period. CONCLUSION: The Ad8 strains causing epidemics of keratoconjunctivitis/conjunctivitis in Norway are genetically stable.