Easy access to vaccination was important for adherence during the 2016-2019 HPV catch-up vaccination in Norway.

Between September and October 2019, the Norwegian Institute for Public Health (NIPH) surveyed women born between 1991 and 1996 who were offered catch-up vaccination for human papilloma virus (HPV). The aim was to identify determinants of vaccine schedule adherence. A random sample of 10,000 women who were offered catch-up vaccination were invited to participate in the survey. We defined adherence as receiving all three doses. Determinants of HPV vaccination adherence were investigated using descriptive, univariable and multivariable logistic regression analyses providing adjusted odds ratios (aOR). Data from 3,762 respondents who received at least one dose were included. Overall, 92.1% (95% CI = 89.3-91.9) of those initiating vaccination adhered to the complete schedule. The following factors were significantly associated with HPV vaccination adherence compared to non-adherence: country of origin (aOR = 0.43; 95% CI = 0.47-0.97), having children (aOR = 0.51; 95% CI = 0.35-0.73), ease of finding out where to get vaccinated (aOR = 1.94; 95% CI = 1.69-2.23), preference for receiving information from health authorities (aOR = 1.37; 95% CI = 1.04-1.81) and vaccination being readily available (aOR = 2.28; 95% CI = 1.50-3.37). Information from NIPH via SMS and social media were negatively associated for Norwegians (aOR = 0.68, 95% CI = 0.46-1.01) and positively associated for those whose country of origin was not Norway (aOR = 1.48, 95% CI = 0.69-3.14; not significant). Those who did not adhere to the full vaccination schedule reported that they had forgotten (40.4%; 95% CI = 33.5-47.8) or had no time (32.9%; 95% CI = 26.2-40.4). Despite NIPH's targeted communication campaign, the main barriers for HPV vaccination adherence were difficulty to find out where to get the vaccine, forgetting to take the vaccine or not having time to complete the schedule.

Sociodemographic determinants of catch-up HPV vaccination completion between 2016-2019 in Norway.

Between 2016 and 2019, a catch-up human papillomavirus (HPV) vaccination took place in Norway for women born between 1991 and 1996. The aim of this study was to identify sociodemographic determinants of complete vaccination (3 doses) and partial vaccination (1-2 doses). A random sample of 10,000 women who were offered catch-up HPV vaccination were invited. We assessed the association between sociodemographic characteristics and vaccination completion using univariable and multivariable multinomial logistic regression.Of 4,967 respondents, 3,464 (63%) received complete vaccination and 298 (7%) received partial vaccination. 30% did not receive any vaccination and functioned as reference group. Compared with having Norwegian caregivers, having a caregiver from non-western countries decreased the odds of partial and complete vaccination (aOR = 0.57; 95%CI = 0.35-0.95 and aOR = 0.57; 95%CI = 0.44-0.74). Having a caregiver from other western countries decreased the odds of complete vaccination (aOR = 0.72; 95%CI = 0.52-0.98). Residing in Norway for 10 years or longer significantly increased the odds of complete vaccination (aOR = 2.65; 95%CI = 1.58-4.43). Being in a relationship significantly increased the odds of partial vaccination compared with being single (aOR = 1.50; 95%CI = 1.02-2.21). Being married (aOR = 0.66; 95%CI = 0.50-0.86) and having children (aOR = 0.53; 95%CI = 0.42-0.68) decreased the odds of complete vaccination. Having university education increased the odds of both partial and complete vaccination (aOR = 2.19; 95%CI = 1.47-3.25 and aOR = 4.11; 95%CI = 3.33-5.06).Having a caregiver born outside of Norway, having children and being married decreased the odds of receiving complete HPV vaccination. This highlights the need to target communication around HPV vaccination toward different ethnic communities and include more specific messaging that having children and being married does not necessarily prevent HPV infections.

Increase of scabies infestations, Norway, 2006 to 2018.

Between October and December 2018, several clinicians in Norway reported an increase in scabies diagnoses. We compared data from the Norwegian Syndromic Surveillance System on medical consultations for mite infestations with scabies treatment sales data to investigate this reported increase. From 2013 to 2018, consultations and sales of scabies treatments had almost increased by threefold, particularly affecting young adults 15-29 years. We recommend to increase awareness among clinicians to ensure timely diagnosis and treatment.

Incidence and factors predicting whooping cough due to parapertussis diagnosis among patients referred to general practitioners, Poland, 2009-2011.

Parapertussis leads to similar symptoms as pertussis, both being caused by bacteria from the genus Bordetella. Poland does not routinely diagnose nor conduct surveillance for parapertussis. We estimated parapertussis incidence and determined predictors of parapertussis diagnosis in the Polish population. Between July 2009 and April 2011, we conducted a prospective cohort study among patients attending 78 general practices. We included patients aged ≥ 3 years, with cough lasting >2 weeks, interviewed patients and collected a nasopharyngeal swab. We confirmed cases by real-time PCR. We estimated parapertussis incidence rates by dividing the number of cases by the summed person-time of observation in respective practices. We assessed predictors of PCR-confirmed parapertussis by comparing cases with patients testing negative. Using logistic regression, we calculated odds ratios (ORs) and 95% confidence intervals (95%CI). We identified 78 cases among 1,231 patients meeting inclusion criteria. The incidence rate was 39/100,000 person-years (95%CI 31-49). The highest rates (140/100,000; 95%CI 74-239), were among children 3-5 years of age and the lowest (24/100,000; 95%CI 13-40) among persons aged 20-39 years of age. Boys aged 3-5 years (7.1; 2.1-25.3) and women aged >40 years (4.1; 1.4-11.7) or living in crowded households (4.3; 1.4-12.9) or contacting persons with prolonged cough (2.3; 1.1-4.5) were more likely to be diagnosed. Our results suggest that laboratory diagnosis could be prioritized for children in the preschool age and women aged over 40 who were referred to their GP with prolonged cough. In the absence of vaccine, post-exposure prophylaxis for close contacts of parapertussis cases could an adequate preventative measure.

Incidence of pertussis in patients of general practitioners in Poland.

We estimated the incidence of pertussis in patients consulting general practitioners (GPs). Between July 2009 and April 2011, we conducted a prospective cohort study of patients attending 78 general practices (158 863 persons overall). We included patients aged ≥ 3 years, with cough lasting 2-15 weeks, who gave informed consent. GPs interviewed eligible patients, collected a blood specimen, and a nasopharyngeal swab. At follow-up 30-60 days after the initial visit, physicians collected a second blood specimen and conducted patient interview. Cases were confirmed by specific IgA and/or IgG antibody titre exceeding significantly the general population background level or detection of bacterial DNA by real-time PCR. During the study period, 3864 patients with prolonged cough consulted the participating GPs, of those 1852 met the inclusion criteria, 1232 were recruited, and 288 were confirmed as pertussis cases (4% by PCR, 96% by serology). The adjusted incidence rate was 201.1/100 000 person-years [95% confidence interval (CI) 133.9-302.0], ranging from 456.5 (95% CI 239.3-870.8) in the 15-19 years group to 94.0 (95% CI 33.4-264.5) in the 25-29 years group. The reporting ratio was 61, ranging from 4 in those aged 3-5 years, to 167 in those aged 65-69 years. The study confirmed high incidence of pertussis in all age groups in the general population, in particular in adults, not appropriately documented by the existing surveillance system.

Antibacterial prescriptions for acute gastrointestinal infections: uncovering the iceberg.

A prospective survey was conducted in patients admitted to 11 randomly selected general practices and eight hospitals located in six provinces of Poland. For each patient meeting the international acute gastrointestinal infection (AGI) case definition criteria, information was collected on healthcare resources used. Antibacterial drug consumption was assessed using defined daily doses (DDD) and extrapolated to the national level using results from a parallel study of AGI incidence in the community. Additionally, a logistic multivariable model was fitted assessing determinants of antibacterial drug administration. Valid questionnaires were collected from 385 general practitioner (GP) consultations and 504 hospital admissions. Antibacterials for systemic use were prescribed during 60 (16%) GP consultations and 179 (36%) hospital admissions. The estimated societal AGI-related consumption of antibacterials amounted to 5·48 million DDD (95% uncertainty interval 1·56-14·12 million DDD). Antibacterial prescription was associated with work in large practices [adjusted odds ratio (aOR) 3·16] and hospital wards (aOR 2·87), compared to small general practices, referral for microbiological testing (aOR 2·88), presence of fever (aOR 2·50), presence of mucus or blood in stool (aOR 1·94), age >65 years vs. <5 years (aOR 1·88), and rural vs. urban residence (aOR 1·53). Despite the fact that antibacterials were prescribed to a minority of consulted AGI patients, their consumption in society was not negligible due to the high prevalence of AGI symptoms. Prescription of antibacterial drugs should be restricted to cases with specific indications, preferably following microbiological investigation of AGI aetiology. To achieve this, clear national recommendations should be widely disseminated to physicians, and included in medical training curricula.

Virus detection in questing ticks is not a sensitive indicator for risk assessment of tick-borne encephalitis in humans.

Tick-borne encephalitis virus (TBEV) is the most important tick-transmitted arbovirus causing human disease in Europe, but information on its endemic occurrence varies between countries because of differences in surveillance systems. Objective data are necessary to ascertain the disease risk for vaccination recommendations and other public health interventions. In two independent, separately planned projects, we used real-time RT-PCR to detect TBE virus in questing ticks. In Poland, 32 sampling sites were selected in 10 administrative districts located in regions where sporadic TBE cases were reported. In Germany, 18 sampling sites were selected in two districts located in a region with high TBE incidence. Altogether, >16,000 ticks were tested by real-time RT-PCR, with no sample testing positive for TBEV. A systematic search for published studies on TBEV prevalence in ticks in Poland and Germany also suggested that testing large numbers of collected ticks could not consistently assure virus detection in known endemic foci. Although assignment of results to administrative regions is essential for TBE risk mapping, this was possible in only 10 (investigating 22,417 ticks) of 15 published studies (>50,000 ticks) identified. We conclude that the collection and screening of ticks by real-time RT-PCR cannot be recommended for assessment of human TBE risk. Alternative methods of environmental TBEV monitoring should be considered, such as serological monitoring of rodents or other wildlife.

Community incidence of pathogen-specific gastroenteritis: reconstructing the surveillance pyramid for seven pathogens in seven European Union member states.

By building reconstruction models for a case of gastroenteritis in the general population moving through different steps of the surveillance pyramid we estimated that millions of illnesses occur annually in the European population, leading to thousands of hospitalizations. We used data on the healthcare system in seven European Union member states in relation to pathogen characteristics that influence healthcare seeking. Data on healthcare usage were obtained by harmonized cross-sectional surveys. The degree of under-diagnosis and underreporting varied by pathogen and country. Overall, underreporting and under-diagnosis were estimated to be lowest for Germany and Sweden, followed by Denmark, The Netherlands, UK, Italy and Poland. Across all countries, the incidence rate was highest for Campylobacter spp. and Salmonella spp. Incidence estimates resulting from the pyramid reconstruction approach are adjusted for biases due to different surveillance systems and are therefore a better basis for international comparisons than reported data.

Influenza A(H1N1)pdm09 vaccination policies and coverage in Europe.

In August 2010 the Vaccine European New Integrated Collaboration Effort (VENICE) project conducted a survey to collect information on influenza A(H1N1)pdm09 vaccination policies and vaccination coverage in the European Union (EU), Norway and Iceland. Of 29 responding countries, 26 organised national pandemic influenza vaccination and one country had recommendations for vaccination but did not have a specific programme. Of the 27 countries with vaccine recommendations, all recommended it for healthcare workers and pregnant women. Twelve countries recommended vaccine for all ages. Six and three countries had recommendations for specific age groups in children and in adults, countries for specific adult age groups. Most countries recommended vaccine for those in new risk groups identified early in the pandemic such as morbid obese and people with neurologic diseases. Two thirds of countries started their vaccination campaigns within a four week period after week 40/2009. The reported vaccination coverage varied between countries from 0.4% to 59% for the entire population (22 countries); 3% to 68% for healthcare workers (13 countries); 0% to 58% for pregnant women (12 countries); 0.2% to 74% for children (12 countries). Most countries identified similar target groups for pandemic vaccine, but substantial variability in vaccination coverage was seen. The recommendations were in accordance with policy advice from the EU Health Security Committee and the World Health Organization.

Incidence of self-reported acute gastrointestinal infections in the community in Poland: a population-based study.

A retrospective cross-sectional survey of self-reported acute gastrointestinal infection (AGI) incidence in the community was performed in Poland, from December 2008 to November 2009. The aim of the study was to estimate the magnitude and distribution of self-reported AGI, in order to calibrate the routine AGI surveillance system in Poland. The study population were randomly selected residents of all Polish regions, having a fixed telephone line. An equal number of telephone interviews were collected each month, requesting the interviewee to identify gastrointestinal symptoms that had occurred in the previous 4 weeks. The international AGI case definition was used. In total 3583 complete interviews were obtained. The compliance ratio was 26%. Of 3583 respondents, 240 (6.7%) individuals fulfilled the AGI case definition. The annualized incidence of acute gastroenteritis was 0.9/person-year (95% confidence interval 0.8-1.0). Comparison of the obtained annual AGI estimate (33.3 million infections) with the number of cases reported to national surveillance during the corresponding period (73 512), yielded an underreporting factor of 453 cases occurring in the community for each reported case. Of the 240 AGI cases, 30.4% consulted a general practitioner, and 4.6% were admitted to hospital. Samples for microbiological confirmation were collected from four (1.6%) cases. This first population-based study in eastern Europe has confirmed that AGI places a high burden on Polish society, which is underestimated by national surveillance data. Efforts are necessary to improve AGI reporting and diagnostic practices in order to increase the effectiveness of the Polish surveillance system in detecting threats related to new AGI pathogens, new routes of transmission or the potential for international spread.

What is the evidence for giving chemoprophylaxis to children or students attending the same preschool, school or college as a case of meningococcal disease?

We performed a systematic literature review to assess the effectiveness of chemoprophylaxis for contacts of sporadic cases of invasive meningococcal disease (IMD) in educational settings. No studies directly compared IMD risk in contacts with/without chemoprophylaxis. However, compared to the background incidence, an elevated IMD risk was identified in settings without a general recommendation for chemoprophylaxis in pre-schools [pooled risk difference (RD) 58·2/105, 95% confidence interval (CI) 27·3-89·0] and primary schools (pooled RD 4·9/105, 95% CI 2·9-6·9) in the ~30 days after contact with a sporadic IMD case, but not in other educational settings. Thus, limited but consistent evidence suggests the risk of IMD in pre-school contacts of sporadic IMD cases is significantly increased above the background risk, but lower than in household contacts (pooled RD for household contacts with no chemoprophylaxis vs. background incidence: 480·1/105, 95% CI 321·5-639·9). We recommend chemoprophylaxis for pre-school contacts depending on an assessment of duration and closeness of contact.

Surveillance of aseptic central nervous system infections in Poland: is it meeting its objectives?

In Poland, a surveillance system capturing generic information on both diagnosed and undiagnosed aseptic central nervous system infections (ACI) has been in operation since 1966. This study evaluates to what extent the ACI surveillance is able to meet its objectives to monitor ACI trends and to detect signals of public health importance such as enteroviral outbreaks, tick-borne encephalitis (TBE) endemic foci, poliovirus appearance or emergence of new neurotropic viruses. Between 2004 and 2008, aetiology was established for 17% of ACI cases. Of the 1,994 reported ACI cases, 232 (11.6%) were diagnosed with TBE virus, 46 (2.3%) with enterovirus, 35 (1.8%) with herpesvirus, and 32 (1.6%) had other viral causes such as Epstein Barr virus or adenovirus. The system's performance varied between the provinces, with the frequency of suspected ACI cases referred for viral aetiology investigation in 2008 ranging from 1.98 to 285.4 samples per million inhabitants. The sensitivity of physicians' reporting, estimated as the proportion of hospitalised ACI cases reported to the surveillance system, was 48% nationally, with vast regional differences (range 30­91%). To conclude, the ACI surveillance system in Poland does currently not meet its objectives, due to limited availability of aetiological diagnosis and microbiological confirmation and to regional differences in reporting sensitivity.

The current state of introduction of human papillomavirus vaccination into national immunisation schedules in Europe: first results of the VENICE2 2010 survey.

The Venice 2 human papillomavirus vaccination survey evaluates the state of introduction of the HPV vaccination into the national immunisation schedules in the 29 participating countries. As of July 2010, 18 countries have integrated this vaccination. The vaccination policy and achievements vary among those countries regarding target age groups, delivery infrastructures and vaccination coverage reached. Financial constraints remain the major obstacle for the 11 countries who have not yet introduced the vaccination.

Differences in national influenza vaccination policies across the European Union, Norway and Iceland 2008-2009.

In 2009 the second cross-sectional web-based survey was undertaken by the Vaccine European New Integrated Collaboration Effort (VENICE) project across 27 European Union (EU) member states (MS), Norway and Iceland (n=29) to determine changes in official national seasonal influenza vaccination policies since a survey undertaken in 2008 and to compare the estimates of vaccination coverage between countries using data obtained from both surveys. Of 27 responding countries, all recommended vaccination against seasonal influenza to the older adult population. Six countries recommended vaccination of children aged between six months and <18 years old. Most countries recommended influenza vaccination for those individuals with chronic medical conditions. Recommendations for vaccination of healthcare workers (HCW) in various settings existed in most, but not all countries. Staff in hospitals and long-term care facilities were recommended vaccination in 23 countries, and staff in out-patient clinics in 22 countries. In the 2009 survey, the reported national estimates on vaccine coverage varied by country and risk group, ranging from 1.1% - 82.6% for the older adult population; to between 32.9% -71.7% for clinical risk groups; and from 13.4% -89.4% for HCW. Many countries that recommend the influenza vaccination do not monitor the coverage in risk groups. In 2008 and 2009 most countries recommended influenza vaccination for the main risk groups. However, despite general consensus and recommendations for vaccination of high risk groups, many countries do not achieve high coverage in these groups. The reported vaccination coverage still needs to be improved in order to achieve EU and World Health Organization goals.

Mass immunisation campaign in a Roma settled community created an opportunity to estimate its size and measles vaccination uptake, Poland, 2009.

During a mass immunisation campaign following an outbreak of measles in a Roma community settled in the town of Pulawy, Poland, we performed an estimation of the size of this Roma population and an assessment of its vaccination uptake. We obtained a list of Roma residing in Pulawy from the local municipality and estimated using a simple capture-recapture formula that Pulawy had 377 Roma residents (43% under 20 years old), which was 27% more than the 295 registered at the municipality. During the vaccination campaign, demographic information was recorded that could be linked to information from the municipality list as well as to prior immunisation status. Among the people whose data were recorded during the vaccination campaign, 14% were not registered at the primary healthcare centres, and were therefore deprived of access to healthcare. Among 102 screened subjects under the age of 20 years, 51% were vaccinated according to schedule. Vaccine uptake for the first dose of measles-containing vaccine was 56% (54/96) and for the second dose 37% (18/49). The present study indicates the need to get a better demographic overview of Roma communities living in Poland and to understand the barriers limiting their access to healthcare and social services. Organisation of catch-up immunisations of this vulnerable population is necessary.

Spotlight on measles 2010: An epidemiological overview of measles outbreaks in Poland in relation to the measles elimination goal.

The objective of this study was to describe transmission chains of measles observed in Poland during 2008-2009. A decade ago, the incidence of measles in Poland declined and approached one case per million inhabitants one of the World Health Organization's criteria for measles elimination. Following a period of very few reported measles cases (2003 to 2005), an increase in incidence was observed in 2006. Since then, the incidence has constantly exceeded one case per million inhabitants. Of 214 measles cases reported in 2008 and 2009 in Poland, 164 (77%) were linked to 19 distinct outbreaks, with 79% of cases belonging to the Roma ethnic group. Outbreaks in the non-Roma Polish population had different dynamics compared to those in the Roma population. On average, measles outbreaks in Roma communities involved 10 individuals, seven of whom were unvaccinated, while outbreaks in the non-Roma Polish population involved five individuals, half of whom were incompletely vaccinated. The majority of outbreaks in Roma communities were related to importation of virus from the United Kingdom. In six outbreaks, the epidemiologic investigation was confirmed by identification of genotype D4 closely related to measles viruses detected in the United Kingdom and Germany. Our data indicate that Poland is approaching measles elimination, but measles virus circulation is still sustained in a vulnerable population. More efforts are needed to integrate the Roma ethnic group into the Polish healthcare system and innovative measures to reach vulnerable groups should be explored.

Spotlight on measles 2010: A measles outbreak in a Roma population in Pulawy, eastern Poland, June to August 2009.

We describe a local indigenous outbreak of measles in a susceptible Roma community, which occurred in Pulawy, a town of 50,000 citizens in the Lubelskie province (eastern Poland) during summer 2009. From 22 June to 30 August 2009, 32 measles cases were reported, and additionally nine possible cases were actively identified. A mass immunisation campaign was organised to stop measles transmission in the Roma community. Active surveillance of rash-febrile illnesses allowed documentation of the impact of mass immunisation in preventing further measles spread in the Roma community, and the surrounding population of Pulawy.

Applied epidemiology training in Europe: quite a success - but more to be done.

This article describes the development of training in applied epidemiology in Europe and outlines the current situation in Europe with a view of how the system can be improved to meet future challenges.

Effectiveness of vaccinating household contacts in addition to chemoprophylaxis after a case of meningococcal disease: a systematic review.

SUMMARYWe performed a systematic review to estimate the effectiveness of vaccination, in addition to chemoprophylaxis, in preventing meningococcal disease among household contacts. Medline, EMBASE, EMGM, and EUIBIS were used for data collection. Studies reporting on at least 100 primary cases and on subsequent cases in household settings with follow-up of more than 2 weeks after onset of disease in the primary case were reviewed. A meta-analysis was used to calculate the average attack rate in household contacts given chemoprophylaxis 14-365 days after onset of disease in the primary case. In total, 652 studies were identified, five studies and one unpublished report met the inclusion criteria. The weighted average attack rate was 1.1/1000 household contacts (95% CI 0.7-1.7). This review supports vaccination of household contacts in addition to chemoprophylaxis to reduce the risk of meningococcal disease among household contacts of a case caused by a vaccine-preventable serogroup.