Legionella transmission from an outdoor fountain in Oslo, Norway. / Legionellose etter smitte fra fontenen på Youngstorget.

BACKGROUND: Most cases of legionellosis in Norway are acquired outside the country. This was a domestic case from an unusual source. CASE PRESENTATION: A man in his thirties was admitted with pneumonia early in the summer. He developed respiratory failure before recovering. Cultures from his lower airways grew Legionella pneumophila serogroup 1. Samples from his home and workplace did not identify Legionella. On further questioning it was discovered that the patient regularly sat beside an outdoor fountain during his breaks from work. Samples from the fountain identified high numbers of L. pneumophila serogroup 1, sequence type 256. Full genome sequencing showed that isolates from the patient and fountain were identical. The fountain used recirculated water with small amounts of chlorine. High outdoor temperatures in Oslo may have facilitated growth of Legionella in the fountain. INTERPRETATION: To our knowledge, this is the first published case of Legionella transmission from an outdoor fountain.

Wanting to or having to - a qualitative study of experiences and attitudes towards migrant screening for tuberculosis in Norway.

BACKGROUND: This study assesses how tuberculosis (TB) screening is perceived by immigrants in Norway. Screening is mandatory for people arriving from high incidence countries. To attend screening, immigrants have to contact the health system after receiving an invitation by letter. The proportion of non-attenders is not known, and there are no sanctions for not attending. Generally, only persons who test positive receive test results. The study explores users' experiences, attitudes and motivations for attending or not attending TB screening, and perceived barriers and enablers. METHODS: We conducted six focus group discussions and three individual interviews with 34 people from 16 countries in Africa, Asia and Europe. Interviews were recorded and transcribed, and data was coded following a general inductive approach: All transcribed text data was closely read through, salient themes were identified and categories were created and labelled. The data was read through several times and the category system was subsequently revised. RESULTS: Most appreciated the opportunity to be tested for a severe disease and were generally positive towards the healthcare system. At the same time, many were uncomfortable with screening, particularly due to the fear and stigma attached to TB. All experienced practical problems related to language, information, and accessing facilities. Having to ask others for help made them feel dependent and vulnerable. Positive and negative attitudes simultaneously created ambivalence. Many wanted "structuring measures" like sanctions to help attendance. Many said that not receiving results left them feeling anxious. CONCLUSIONS: In order to adapt the system and improve trust and patient uptake, all aspects of the screening should be taken into account. Ambivalence towards screening probably has a negative impact on screening uptake and should be sought reduced. A combination of ambivalence and a wish for "structuring measures" leads the authors to conclude that mandatory screening is a reasonable measure. However, since mandatory screening negatively impacts patient autonomy, and because of fear, stigma and practical problems, the health system should empower users by improving communication and access to services. In addition, it is recommended that negative test results are also communicated to the users.

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.

[Cases of MRSA in nursing homes in Oslo 2005-11]. / MRSA-funn i sykehjem i Oslo 2005-11.

BACKGROUND: The number of infections caused by MRSA has increased substantially in Norway in the past decade. It is an objective to prevent MRSA from becoming established in nursing homes and hospitals. The purpose of the article is to describe the features of the development of MRSA cases found in nursing homes in Oslo. MATERIALS AND METHOD: We carried out a retrospective study of registered cases of MRSA (both sufferers and carriers) in Oslo in 2005-11. Data were obtained from the City of Oslo municipal health services' MRSA database and from genotyping carried out at Akershus University Hospital. RESULTS: The annual number of cases of MRSA found in Oslo increased during the period 2005-11 from 92 in 2005 to 268 in 2011, a total of 1198 cases. Of these, 224 cases (19%) were registered in nursing homes, distributed among 22 institutions, 158 residents and 66 staff, with an average of 32 cases annually (14-58 spread). Twenty-eight of 50 nursing homes had no cases of MRSA, while 159 of the cases were related to outbreaks of MRSA. Three of 20 outbreaks affected residents only. The nursing home isolates consisted of 40 different spa types, of which 160 (71%) of the isolates were clustered in three clonal complexes. The most common spa type t304 was found in 116 (52%) of the cases. INTERPRETATION: Cases of MRSA in Oslo in total increased sharply from 2005 to 2011, while the number of cases in nursing homes was stable. It is, however, uncertain whether this reflects the actual incidence.

HIV as a risk factor for cardiac disease in Botswana: a cross-sectional study.

The primary objective of this study was to assess how HIV has influenced the spectrum of heart diseases in Botswana and to examine the HIV prevalence among patients with cardiomegaly. The secondary objective was to evaluate the value of the cardiothoracic (CT) ratio on chest radiography (CXR) as a screening tool for cardiac disease. In total, 179 patients (age 14-97 years) with cardiomegaly (all CT ratios >0.53 on CXR) and known HIV status were referred to Botswana's sole hospital-based echocardiographic centre. Clinical examination and echocardiography were performed. Cardiomyopathy (36.9%), pericarditis (21.2%), hypertensive heart disease (14.0%), rheumatic heart disease (8.4%) and right-sided heart failure (6.7%) were the main causes of cardiomegaly; only two patients had a normal echocardiogram. The HIV prevalence was higher than in the general population [59% vs 25%; relative risk (RR) of HIV infection compared with the general population 2.4, 95% CI 2.1-2.7]. HIV infection was strongly associated with pericarditis (RR 3.3, 95% CI 2.8-3.8) and cardiomyopathy (RR 2.9, 95% CI 2.4-3.5). These data suggest an increased risk of non-ischaemic heart disease, in particular pericarditis and cardiomyopathy, among HIV-infected patients. The CT ratio on CXR had high specificity in detecting severe heart disease and can be a useful screening tool in areas with limited resources.

[How to combat HIV, tuberculosis and malaria?]. / Hvordan bekjempe hiv, tuberkulose og malaria?

BACKGROUND: In year 2 000, the United Nations (UN) agreed on eight millennium development goals (MDGs). Goal number 6 is to combat HIV/AIDS, malaria and other communicable diseases, including tuberculosis. The aim of this paper is to provide an overview of current status and prognosis for this MDG, and to discuss strategies that need to be implemented to reach the goal. MATERIAL AND METHODS: The article is mainly based on publications from the UN or WHO-affiliated organizations. RESULTS: The global HIV prevalence rate has remained at 0.8 % for the last ten years, but the total infected population is still increasing. Access to treatment has increased considerably, but only 28 % of those in need of treatment (and living in developing countries), received it in 2007. Global tuberculosis incidence and prevalence rates of tuberculosis are falling, but not in Europe and Africa. For malaria, there is more uncertainty, but there seems to be a declining incidence in many countries. INTERPRETATION: The MDG for HIV/AIDS cannot be reached by treatment alone, continued emphasis on prevention and more specific prevention strategies is necessary. The global targets for tuberculosis can be reached, but probably not in Africa; in addition, multi-resistant tuberculosis is increasing. Modern combination treatment, impregnated bednets and indoor residual spraying has led to a substantial reduction in the prevalence of malaria during few years in African countries.

[Risk factors for hepatitis C among injecting drug users in Oslo]. / Risikofaktorer for hepatitt C-smitte blant sprøytemisbrukere.

BACKGROUND: Hepatitis C virus (HCV) infection is common among injecting drug users. The aims of this study were to assess the prevalence of risk behaviour and its association with HCV infection. MATERIAL AND METHODS: All users of the needle exchange program in Oslo, within a given time period, were eligible for inclusion in this cross-sectional study; 327 chose to participate. The users were asked about type of drug use and risk behaviour for HCV exposure in a structured interview. Sera were drawn and tested for anti HCV (EIA-3) and HCV RNA (in- house PCR). RESULTS: The prevalence of HCV RNA was 51 % and 81 % had anti-HCV. A multivariate analysis revealed positive associations between anti-HCV positive status and age < 20 years at first injection, > 5 years of drug use, age > 34 years, sharing of syringes, injecting drug use while imprisoned, back-loading and use of heroin. One in five users with anti-HCV reported to never have shared syringes. However, sharing of drug paraphernalia other than needles was not associated with anti-HCV. Sharing of needles the last four weeks before the interview was more common among those living with a partner than those who lived alone. INTERPRETATION: Most injecting drug users in Oslo have been exposed to HCV (anti HCV+) and half of them have developed chronic infection (HCV RNA+). HCV was associated with back-loading and sharing of syringes - especially during incarceration. Sharing of injection paraphernalia was not associated with being anti HCV positive.

[An outbreak of MRSA in a nursing home in Oslo]. / Et MRSA-utbrudd i et sykehjem i Oslo.

BACKGROUND: Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) represent an increasing problem in Norway, also in nursing homes and other institutions for long-term care. We describe an outbreak of MRSA in a nursing home in Oslo 2004-5. MATERIAL AND METHODS: The nursing home has six wards with 185 beds. The building is old, all rooms have toilets and sinks, but showers are shared. Standard screening procedures were carried out according to the national MRSA guide and by using the nursing home's infection control programme. Later on we used more extensive screening of staff and patients. RESULTS: The outbreak started in a ward for short-term care, but spread to a ward for patients with dementia after some months. Ten patients, seven staff members and two relatives of infected persons were diagnosed with MRSA. All bacteria probably belonged to the same strain. Four staff members and five patients who were infected had pre-existing wounds or eczema. The nursing home was declared free of MRSA 20 months after the outbreak started, but one member of staff remained a carrier for two years, and one patient became a chronic carrier of MRSA. During the first six months, infected patients were restricted to their rooms, and standard eradication procedures were carried out for five days. Later on, we introduced cohort isolation for infected, exposed and recently treated patients, a different screening routine, a prolonged eradication procedure, restrictions on staff working elsewhere and more stringent precautions for visitors. INTERPRETATION: An old building and insufficient isolation procedures during the first phase of the outbreak contributed to spreading MRSA and prolonging the outbreak. Cohort isolation seemed to be the most important measure to control the outbreak. All nursing homes should have a designated single patient room for contact precautions. Long-term carriers of MRSA in nursing homes represent a big challenge.

[Hepatitis C--a health problem also in Norway]. / Hepatitt C--et helseproblem også i Norge.

BACKGROUND: Hepatitis C is a large global health problem; approximately 20 - 30 000 are infected in Norway. Hepatitis C-infection is often chronic and can progress into chronic liver disease, liver cirrhosis and hepatocellular carcinoma. The most important transmission route is through percutaneous exposure to infected blood. The aim of this article is to describe the clinical course, microbiological diagnostic approaches, therapy, prophylaxis and public health aspects of Hepatitis C infection. MATERIAL AND METHODS: The paper is based on results from annual health examinations (conducted since 2001) of persons who abuse drugs intravenously in Oslo, from diagnostic work in a national reference laboratory for Hepatitis C and studies of literature (retrieved from Pubmed). RESULTS AND INTERPRETATION: The prevalence of Hepatitis C varies by country and subgroup of patients. In Norway the prevalence is 0.13 % among new blood donors, 0.7 % among pregnant women, 0.55 % in the general adult population and approximately 70 % among persons who abuse drugs intravenously. Treatment with pegylated interferon and ribavirin induces sustained virological response in 80 % of patients with genotypes 2 and 3 and in 30 - 40 % of those with genotype 1.

Two and a half years of routine HIV testing in Botswana.

BACKGROUND: Botswana was the first African country to introduce routine HIV testing (RHT). OBJECTIVE: To report program data for the first 2.5 years of RHT. METHODS: RHT was introduced in 2004. Rapid HIV tests were introduced later the same year and are widely available. The main criteria for RHT are symptoms of HIV/AIDS, pregnancy, sexually transmitted infection, and attendance for medical examination. Testing may also be self-initiated. FINDINGS: There has been a rapid scale-up of RHT. A total of 60,846 persons were tested through RHT in 2004 versus 157,894 in 2005 and 88,218 in the first half of 2006. Testing rates in the population through RHT were 40 per 1000 persons, 93 per 1000 persons, and 104 per 1000 persons, respectively. In 2005, 89% of those offered testing accepted, with 69% of those tested being female and 31% male. The proportion of men who tested HIV-positive was 34% versus 30% for women. The main reasons for testing in 2005 were patient's wish (50%), pregnancy (25%), medical examination (7%), clinical suspicion (6%), and sexually transmitted infection (2%). Attendance at voluntary counseling and testing centers has increased parallel to the scale-up of RHT. CONCLUSIONS: RHT has been widely accepted by the population, and no adverse effects or instances have been reported. It has provided increased access to preventive services and earlier assessment for antiretroviral treatment. We believe the benefits of RHT clearly outweigh the risks.

[The HIV-pandemic in the third world--worse than anticipated?]. / Hivepidemien i den tredje verden--verre enn forventet?

BACKGROUND: The first AIDS cases were discovered 25 years ago in the United States. We describe how the epidemic evolved in the Third World, with emphasis on the current situation and on the African continent, which is most affected. METHODS: The present review article is based on a literature review and own working experience. RESULTS AND INTERPRETATION: In 2005, more than 90 % of HIV-infected persons lived in Third World countries, mainly Africa and Asia. Transmission in Africa is mainly heterosexual and approximately 60 % of the infected are women. Asia has epidemics among intravenous drug users and men who have sex with men, and among sex workers and their customers. Several Asian countries now have generalized epidemics. Urban populations are more affected than rural ones in all geographical areas of the world, with only a few exceptions. Modern HIV treatment saves many lives, but only an increase of preventive measures can reverse the current trends. To obtain a reversal, it is adamant with broad mobilization of affected populations, clear political leadership and prioritisation and a considerable increase in help from developed countries.

Patient and health care system delays in the start of tuberculosis treatment in Norway.

BACKGROUND: Delay in start of tuberculosis (TB) treatment has an impact at both the individual level, by increasing the risk of morbidity and mortality, and at the community level, by increasing the risk of transmission. The aims of this study were to assess the delays in the start of treatment for TB patients in Oslo/Akershus region, Norway and to analyze risk factors for the delays. METHODS: This study was based on information from the National TB Registry, clinical case notes from hospitals and referral case notes from primary health care providers. Delays were divided into patient, health care system and total delays. The association with sex, birthplace, site of the disease and age group was analyzed by multiple linear regression. RESULTS: Among the 83 TB patients included in this study, 71 (86%) were born abroad. The median patient, health care system and total delays were 28, 33 and 63 days respectively, with a range of 1-434 days. In unadjusted analysis, patient delay and health care system delay did not vary significantly between men and women, according to birthplace or age group. Patients with extra-pulmonary TB had a significantly longer patient, health care system and total delay compared to patients with pulmonary TB. Median total delay was 81 and 56 days in the two groups of TB patients respectively. The health care system delay exceeded the patient delay for those born in Norway. The age group 60+ years had significantly shorter patient delay than the reference group aged 15-29 years when adjusted for multiple covariates. Also, in the multivariate analysis patients born in Norway had significantly longer health care system delay than patients born abroad. CONCLUSION: A high proportion of patients had total delays in start of TB treatment exceeding two months. This study emphasizes the need of awareness of TB in the general population and among health personnel. Extra-pulmonary TB should be considered as a differential diagnosis in unresolved cases, especially for immigrants from high TB prevalence countries.

[Prevalence of genital Chlamydia trachomatis infection in the age group 18-29 years in Oslo]. / Forekomst av genital infeksjon med Chlamydia trachomatis blant 18-29-åringer i Oslo.

BACKGROUND: Earlier Norwegian prevalence studies of genital C. trachomatis infection have mainly been carried out among women and in selected patient groups. We decided to do a population-based prevalence study among young men and women in Oslo. The study was done within the framework of the new Norwegian list patient system, in which each citizen is assigned to one particular doctor. METHODS: Cross-sectional study. All patients 18-29 years old listed with a group practice in Oslo received a personal letter of invitation. We asked each person to submit a urine sample and fill in a questionnaire. The urinary samples were tested by means of a DNA amplification method. Non-respondents received one reminder. RESULTS: 685 persons were invited to participate, 234 responded (36%); 169 females (43%) and 65 males (25%). A total of 6 respondents (3%, 95% CI 1.2-5.5) tested positively, 4 of them were males. At least 51% of the females and 25% of the males had previously been examined for C. trachomatis, and at least 18% of the females and 8% of the males had received treatment. A total of 70% stated that they would see their doctor if they suspected a genital chlamydial infection. INTERPRETATION: Opportunistic testing for C. trachomatis infection should be offered more frequently to young men. A national prevalence study of genital chlamydial infection should be carried out. The new list patient system offers new opportunities for research in primary medical care in Norway.

Treatment outcome of new culture positive pulmonary tuberculosis in Norway.

BACKGROUND: The key elements in tuberculosis (TB) control are to cure the individual patient, interrupt transmission of TB to others and prevent the tubercle bacilli from becoming drug resistant. Incomplete treatment may result in excretion of bacteria that may also acquire drug resistance and cause increased morbidity and mortality. Treatment outcome results serves as a tool to control the quality of TB treatment provided by the health care system. The aims of this study were to evaluate the treatment outcome for new cases of culture positive pulmonary TB registered in Norway during the period 1996-2002 and to identify factors associated with non-successful treatment. METHODS: This was a register-based cohort study. Treatment outcome was assessed according to sex, birthplace, age group, isoniazid (INH) susceptibility, mode of detection and treatment periods (1996-1997, 1998-1999 and 2000-2002). Logistic regression was also used to estimate the odds ratio for treatment success vs. non-success with 95% confidence interval (CI), taking the above variables into account. RESULTS: Among the 655 patients included, the total treatment success rate was 83% (95% CI 80%-86%). The success rates for those born in Norway and abroad were 79% (95% CI 74%-84%) and 86% (95% CI 83%-89%) respectively. There was no difference in success rates by sex and treatment periods. Twenty-two patients (3%) defaulted treatment, 58 (9%) died and 26 (4%) transferred out. The default rate was higher among foreign-born and male patients, whereas almost all who died were born in Norway. The majority of the transferred out group left the country, but seven were expelled from the country. In the multivariate analysis, only high age and initial INH resistance remained as significant risk factors for non-successful treatment. CONCLUSION: Although the TB treatment success rate in Norway has increased compared to previous studies and although it has reached a reasonable target for treatment outcome in low-incidence countries, the total success rate for 1996-2002 was still slightly below the WHO target of success rate of 85%. Early diagnosis of TB in elderly patients to reduce the death rate, abstaining from expulsion of patients on treatment and further measures to prevent default could improve the success rate further.