Meticillin-resistant Staphylococcus aureus in Norway, a low-incidence country, 2006-2010.

BACKGROUND: Antibiotic resistance is a global public health threat. Norway has managed to keep the incidence of resistant bacteria at a low level in both the healthcare system and the community. Reporting of both individual cases and meticillin-resistant Staphylococcus aureus (MRSA) outbreaks is mandatory. All isolates are genotyped. AIM: To describe the epidemiology of MRSA in Norway and to analyse how MRSA is spreading in a low-incidence country. METHODS: All cases of laboratory-confirmed MRSA colonisation and infection reported in Norway from 2006 to 2010 were subject to epidemiological analysis. FINDINGS: A total of 3620 cases of MRSA were found. Around one-third of the cases were imported, one-third acquired in the Norwegian healthcare system and one-third acquired in the community. Twelve percent of the cases were linked to known outbreaks. The total incidence of infected and colonized patients is slowly increasing. The numbers of severe infections remain stable at around 20 cases annually and the proportion of MRSA cases associated with healthcare has decreased. CONCLUSION: MRSA is still rare in the Norwegian population and the strategic objective of preventing MRSA from becoming a permanent part of the bacterial flora in hospitals and nursing homes has so far been met.

Salmonellosis and charter tourism: epidemiology and trends of imported human cases to Norway from the Canary Islands and Thailand, 1994-2008.

More than 70% of reported human Salmonella infections in Norway are infected abroad. The Canary Islands and Thailand are two of the most popular charter tourist destinations for Norwegians. Using surveillance data for the years 1994-2008, and denominator data on travel to the Canary Islands 2000-2008 and to Thailand 1997-2008, we present the epidemiology and trends of Salmonella infections in Norwegian tourists to these destinations. We found a declining trend in risk of salmonellosis in tourists returning from the Canary Islands, and a change in serovar distribution in travellers to Thailand with more S. Enteritidis infections, similar to that observed in Western European countries. The use of denominator data is important when studying risk of travel-related disease, as surveillance data tend to reflect travel activity more than the risk. Infections among tourists do not always affect the local residents and therefore may not be detected by local public health authorities. Sharing knowledge on the epidemiology of infections in tourists could be useful for observation of changes in trends in the countries visited, and in future outbreak investigations.

Differences and commonalities of national field epidemiology training programmes in Europe.

From 1994 to 2009, national field epidemiology training programmes (FETP) have been installed in Spain, Germany, Italy, France and Norway. During their two year duration, different components of the FETP are devised as follows: 63-79 weeks are spent on projects in hosting institutes, 2-26 weeks in outside projects, 9-30 weeks in courses and modules, and 1-2 weeks in scientific conferences. A considerable proportion of the Spanish FETP has is provided conventional class room training . The content of the modules is very similar for all programmes. Except from the Italian programme, all focus on infectious disease epidemiology. The German and Norwegian programmes are so called EPIET-associated programmesas their participants are integrated in the modules and the supervision offered by EPIET, but salaries, facilitators, and training sites are provided by the national programme. These EPIET-associated programmes require strong communications skills in English. Alumni of all five FETP are generally working within the public health work force in their respective countries or at international level, many of them in leading functions. Although three new FETP have been installed since the last published Euroroundup in Eurosurveillance on European FETP in 2001, the progress with respect to the establishment of national FETP or EPIET-associated programmes has been slow. Member States should be aware of how much support EPIET can offer for the establishment of national FETP or EPIET-associated programmes. However, they also need to be ready to provide the necessary resources, the administrative environment and long-term dedication to make field epidemiology training work.

Severe consequences of healthcare-associated infections among residents of nursing homes: a cohort study.

The aim of this study was to identify the consequences of healthcare-associated infections in Norwegian nursing homes, to include debilitation, hospital transfer and mortality. We followed the residents of six nursing homes in two major cities in Norway during the period October 2004 to March 2005. For each resident with infection we randomly selected two controls among residents who did not have an infection. Cases and the controls were followed for 30 days as a cohort in order to measure the incidence of complications and risk ratio (RR) in the two groups. The incidence of infection was 5.2 per 1000 resident-days. After 30 days follow-up 10.9% of residents who had acquired infection demonstrated a reduction in overall physical condition compared with 4.8% in the unexposed group (RR: 2.3). Altogether 13.0% of residents with infections were admitted to hospital compared with 1.4% in the unexposed group (RR 9.2), and 16.1% residents with infections died in the nursing home during follow-up compared with 2.4% in the unexposed group (RR: 6.6). Residents with lower respiratory tract infections demonstrated higher morbidity and mortality. In conclusion, healthcare-associated infections cause severe consequences for people living in nursing homes, including debilitation, hospital admission and death.

A local outbreak of quinolone-resistant gonorrhoea in Norway, January 2008.

Since 1994, the incidence of gonorrhoea in Østfold county, Norway, has remained within the range of 1-8 cases per year, with 40% of cases being imported from abroad. On 20 January 2008, a general practitioner in the county diagnosed two seemingly unrelated domestic cases of gonorrhoea in three days and started contact tracing. A case was defined as a person with clinical symptoms of gonorrhoea who was a part of the sexual network. Available isolates from the samples taken were tested for resistance. Among 13 contacts identified in the sexual network, eight were classified as cases on the basis of symptoms, four of whom had laboratory-confirmed gonorrhoea. The index case acquired the infection abroad. The three isolated strains were resistant to ciprofloxacin, but sensitive to ceftriaxone which was used for treatment. In the outbreak described, most cases were diagnosed only after contact tracing although they had had symptoms. A quinolone-resistant strain was imported from abroad and introduced into the population. The Norwegian national treatment guidelines, which still recommend quinolones for empirical treatment, should be updated.

Safety review: two outer membrane vesicle (OMV) vaccines against systemic Neisseria meningitidis serogroup B disease.

MenBvac is an OMV vaccine against systemic serogroup B Neisseria meningitidis disease. MenBvac was developed for control of a B:15:P1.7,16 subtype epidemic in Norway and administered to 180,000 subjects in 28 clinical studies. MeNZB, a daughter vaccine of MenBvac, was developed for a clonal B:4:P1.7b,4 epidemic in New Zealand and administered to 1 million people <20 years. The vaccines were similar regarding reactogenicity profile. Serious adverse events (SAEs) in general and particularly neurologic SAEs were very rare. Despite frequently reported local reactions and fever in those under 5 years, these OMV-based vaccines containing 25 microg antigen can be considered safe for use in all age groups.

Healthcare-associated infection among residents of long-term care facilities: a cohort and nested case-control study.

Knowledge of infection control measures in nursing homes is limited. This study aimed to assess the incidence of, and potential risk factors for, healthcare-associated infection in long-term care facilities in Norway. Incidence of healthcare-associated infection was recorded prospectively in six long-term care facilities located in two major cities in Norway between 1 October 2004 and 31 March 2005. For each resident with an infection we aimed for two controls in a nested case-control study to identify potential risk factors. Incidence of infection was 5.2 per 1000 resident-days. Urinary and lower respiratory tract infections were the most common. Patients confined to their beds [odds ratio (OR=2.7)], who stayed <28 days (OR=1.5), had chronic heart disease (OR=1.3), urinary incontinence (OR=1.5), an indwelling urinary catheter (OR=2.0) or skin ulcers (OR=1.8) were shown to have a greater risk for infection. Age, sex and accommodated in a two- versus single-bed room were not significant factors. Incidence of infection in nursing homes in Norway is within the range reported from other countries. This study identified several important risk factors for healthcare-associated infection. There is a need to prevent infection by implementing infection control programmes including surveillance in long-term care facilities.

Emerging Salmonella Enteritidis anaerogenic phage type 14b: outbreak in Norwegian, Swedish and Finnish travellers returning from Greece.

In July 2001, the Norwegian Institute of Public Health (Folkehelseinstituttet, FHI) reported a cluster of Salmonella Enteritidis of phage type 14b infections in Norwegian travellers returning from Greece. An increase in the same uncommon phage type was also registered in Sweden and Finland at the same time. Cases of S. Enteritidis PT 14b in patients returning from Greece were reported in these three Nordic countries in 2001 (303 cases), 2002 (164 cases) and 2003 (199 cases). Case-control studies performed in 2001 in Norway and Sweden indicated that consumption of chicken was associated with illness. In 2002 and 2003, continuing case reports indicated that this uncommon phage type had probably become established in the Greek food chain. Tour operators were informed and contacts were made with Greek public health authorities. Because place of infection is not systematically included in most Salmonella notification systems, the S. Enteritidis phage type 14b outbreak reported here may represent only part of a larger outbreak among travellers visiting Greece. Infections are often reported only in the tourists' home countries and public health authorities in the tourist destinations may not be aware of the problem. Further collaboration between national institutes of public health in Europe is needed to detect outbreaks occurring among tourists.

Emerging Salmonella Enteritidis anaerogenic phage type 14b: Outbreak in Norwegian, Swedish and Finnish travellers returning from Greece.

In July 2001, the Norwegian Institute of Public Health (Folkehelseinstituttet, FHI) reported a cluster of Salmonella Enteritidis of phage type 14b infections in Norwegian travellers returning from Greece. An increase in the same uncommon phage type was also registered in Sweden and Finland at the same time. Cases of S. Enteritidis PT 14b in patients returning from Greece were reported in these three Nordic countries in 2001 (303 cases), 2002 (164 cases) and 2003 (199 cases). Case-control studies performed in 2001 in Norway and Sweden indicated that consumption of chicken was associated with illness. In 2002 and 2003, continuing case reports indicated that this uncommon phage type had probably become established in the Greek food chain. Tour operators were informed and contacts were made with Greek public health authorities. Because place of infection is not systematically included in most Salmonella notification systems, the S. Enteritidis phage type 14b outbreak reported here may represent only part of a larger outbreak among travellers visiting Greece. Infections are often reported only in the tourists' home countries and public health authorities in the tourist destinations may not be aware of the problem. Further collaboration between national institutes of public health in Europe is needed to detect outbreaks occurring among tourists.

Prevalence of nosocomial infections in hospitals in Norway, 2002 and 2003.

The Norwegian Institute of Public Health initiated a national surveillance system for nosocomial infections in 2002. The system is based on two annual one-day prevalence surveys recording the four most common types of nosocomial infection: urinary tract infections; lower respiratory tract infections; surgical site infections and septicaemia. All acute care hospitals in Norway (N=76) were invited to participate in the four surveys in 2002 and 2003. The total prevalence of the four recorded nosocomial infections varied between 5.1% and 5.4% in the four surveys. In all surveys, nosocomial infections were located most frequently in the urinary tract (34%), followed by the lower respiratory tract (29%), surgical sites (28%) and septicaemia (8%). The prevalence surveys give a brief overview of the burden and distribution of nosocomial infections. The results can be used to prioritize further infection control measures and more detailed incidence surveillance of nosocomial infections.

Communicable disease control in a migrant seasonal workers population: a case study in Norway.

Reliable data on the health status of migrant seasonal workers in Europe is scarce. Access to public health care for this population depends on national regulations, and their legal status in host countries. In this manuscript we describe a case study of a salmonellosis outbreak that occurred in Norway, and highlight the difficulties encountered in applying control measures in a population of seasonal migrant farm workers. Surveillance and control of infectious diseases need to be supported by legislation which makes implementation of control measures possible. Efforts have been made to improve the rights for migrants in Europe with regard to healthcare, but seasonal migrant workers still remain largely outsiders where these measures are concerned. Special attention should be given to this disadvantaged group in terms of social rights and healthcare. Preparedness plans should be improved to deal with contagious pathogens involving the seasonal migrant population.

Communicable disease control in a migrant seasonal workers population: A case study in Norway.

Reliable data on the health status of migrant seasonal workers in Europe is scarce. Access to public health care for this population depends on national regulations, and their legal status in host countries. In this manuscript we describe a case study of a salmonellosis outbreak that occurred in Norway, and highlight the difficulties encountered in applying control measures in a population of seasonal migrant farm workers. Surveillance and control of infectious diseases need to be supported by legislation which makes implementation of control measures possible. Efforts have been made to improve the rights for migrants in Europe with regard to healthcare, but seasonal migrant workers still remain largely outsiders where these measures are concerned. Special attention should be given to this disadvantaged group in terms of social rights and healthcare. Preparedness plans should be improved to deal with contagious pathogens involving the seasonal migrant population.

Outbreak of Salmonella Livingstone infection in Norway and Sweden due to contaminated processed fish products.

In Europe, the number of reported sporadic human cases of Salmonella Livingstone infection is low, and outbreaks are rare. We report the largest S. Livingstone outbreak described in the literature having an identified source of infection. In February 2001, an increased incidence of infection caused by S. Livingstone was observed in Norway and Sweden. By July 2001, 44 cases were notified in Norway and 16 in Sweden. The median age was 63 years, and 40 were women. There were three deaths, and 22 patients were hospitalized. Based on standardized questionnaires and retrospective studies of S. Livingstone strains in Norway and Sweden, food items with egg powder were suspected, and S. Livingstone was subsequently recovered from a processed fish product at the retail level. Analysis by pulsed-field gel electrophoresis documented that isolates from the fish product belonged to the same clone as the outbreak strain.

Case management of a multidrug-resistant Shigella dysenteriae serotype 1 outbreak in a crisis context in Sierra Leone, 1999-2000.

From December 1999 to the end of February 2000, 4218 cases of dysentery were reported in Kenema district, southeastern Sierra Leone, by a Médecins Sans Frontières team operating in this region. Shigella dysenteriae serotype 1 was isolated from the early cases. The overall attack rate was 7.5% but higher among children under 5 years (11.2%) compared to the rest of the population (6.8%) (RR = 1.6; 95% CI 1.5-1.8). The case fatality ratio was 3.1%, and higher for children under 5 years (6.1% vs. 2.1%) (RR = 2.9; 95% CI 2.1-4.1). A case management strategy based on stratification of affected cases was chosen in this resource-poor setting. Patients considered at higher risk of death were treated with a 5 day ciprofloxacin regimen in isolation centres. Five hundred and eighty-three cases were treated with a case fatality ratio of 0.9%. Patients who did not have signs of severity when seen by health workers were given hygiene advice and oral rehydration salts. This strategy was effective in this complex emergency.

Prevalence of nosocomial infections and use of antibiotics in long-term care facilities in Norway, 2002 and 2003.

There were 42900 institution-beds in long-term care facilities for elderly persons in Norway in 2000. This is twice as many as in 1984. Of those living in an elderly people's care institution 77% were above 80 years. To determine the magnitude and distribution of nosocomial infections in such institutions, the Norwegian Institute of Public Health initiated a surveillance system. The system is based on two annual one-day prevalence surveys recording the four most common nosocomial infections: urinary tract infections, lower respiratory tract infections, surgical-site infections and skin infections, as well as antibiotic use. All long-term care facilities were invited to participate in the four surveys in 2002 and 2003. The total prevalence of the four recorded nosocomial infections varied between 6.6 and 7.3% in the four surveys. Nosocomial infections occurred most frequently in the urinary tract (50%), followed by infections of the skin (25%), of the lower respiratory tract (19%) and of surgical sites (5%). The prevalence of nosocomial infections was highest in rehabilitation and short-term wards, whereas the lowest prevalence was found in special units for persons with dementia. In all the surveys the prevalence of the four recorded nosocomial infections was higher than the prevalence of patients receiving antibiotics. The frequency of nosocomial infections in such facilities highlights the need for nosocomial infection surveillance in this population and a need to implement infection control measures, such as infection control programmes including surveillance of nosocomial infections.