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Background: Tuberculosis is a major global public health challenge, and a majority of countries have adopted a version of the global strategy to fight Tuberculosis, Directly Observed Treatment, Short Course (DOTS). Drawing on results from research in Ethiopia and Norway, the aim of this paper is to highlight and discuss ethical aspects of the practice of Directly Observed Treatment (DOT) in a cross-cultural perspective., Discussion: Research from Ethiopia and Norway demonstrates that the rigid enforcement of directly observed treatment conflicts with patient autonomy, dignity and integrity. The treatment practices, especially when imposed in its strictest forms, expose those who have Tuberculosis to extra burdens and costs. Socially disadvantaged groups, such as the homeless, those employed as day labourers and those lacking rights as employees, face the highest burdens., Summary: From an ethical standpoint, we argue that a rigid practice of directly observed treatment is difficult to justify, and that responsiveness to social determinants of Tuberculosis should become an integral part of the management of Tuberculosis.

Aim: Directly observed treatment (DOT) has been implemented globally as a strategy in treatment of tuberculosis. Studies from high-endemic settings show that DOT involves social and economical burdens for patients, but little is known about experiences with practicing DOT in low-endemic settings. The present study explores patients' and health professionals' views and experiences with DOT in Norway., Method: In-depth interviews were conducted with 22 patients originating from Somalia and Ethiopia and with 20 health professionals. Data from the interviews were analysed using systematic text condensation., Findings: We found that there was little room for patients to negotiate whether or not to consent to the organization of treatment (DOT). Patients told that it was difficult to question the way treatment was organized, as they got the impression that there was no other way of gaining access to medication. Both patients and health professionals reported that persuasion based on authority and subtle threats was used as means to facilitate patients' acceptance of DOT. A majority of patients experienced DOT as humiliating and discriminating, while some had the experience of being cared for. Patients who attended school or had occupational obligations reported high social costs related to the treatment. Patients with positive experiences told that they had been given an opportunity to negotiate flexible treatment schedules and emphasized the importance of continuity among health professionals. Health professionals had divergent views and practices. Some argued that patients should be treated equally, while others argued for an individualized and flexible approach., Conclusion: The practice of DOT reflects societal power structures that influence the clinical interactions between health professionals and patients. To avoid experiences of disempowerment and humiliation among patients, treatment and care should be organized in a way that safeguards patients' right to consent to treatment and that allows patients to negotiate an individualized treatment schedule., (© 2011 The Authors. Scandinavian Journal of Caring Sciences © 2011 Nordic College of Caring Science.)

Birds are capable of transporting ticks and, consequently, tick-borne pathogens over long distances and across geographical barriers such as oceans and deserts. The purpose of this study was to assess the prevalence of Borrelia spp. in ticks transported by birds by using PCR. A total of 9768 northward-migrating passerine birds was examined for ticks at 4 bird observatories along the southern Norwegian coast during their spring migration in 2003-2005. Two of the bird observatories were located on islands where flagging revealed very few or no ticks (Akerøya and Store Færder), while the other 2 were located in areas with established dense tick populations: an island, Jomfruland (>100 ticks per hour of flagging) and a mainland locality, Lista (40 ticks in one hour of flagging). Borrelia spp. were found in 70 (13.6%) of 513 examined Ixodes ricinus nymphs (19 B. afzelii, 38 B. garinii, two B. turdi, and 11 B. valaisiana) and in 14 (8.1%) of 172 examined I. ricinus larvae (ten B. garinii, one B. turdi, and three B. valaisiana). This report is the first to identify B. turdi in Europe. Ticks collected from birds of the genus Turdus (T. merula, T. philomelos, and T. iliacus) had a higher prevalence of Borrelia spp. than ticks from the other passerine genera. Ticks that were cofeeding with a Borrelia-infected tick had an increased probability of being infected with the same Borrelia species. Ticks collected on birds from the south-western locality Lista were less likely to have Borrelia than ticks found on birds from the other, more eastern localities. The Turdus spp. are particularly important, both because they carry many ticks per bird and because ticks carried by these species have a higher prevalence of Borrelia. This higher prevalence may be related to Borrelia infection of the birds or transmission of Borrelia through cofeeding. The prevalence of the different Borrelia species in ticks collected from migratory birds may be related to migration routes., (2010 Elsevier GmbH. All rights reserved.)

Background: The incidence of bovine babesiosis, caused by Babesia divergens (Apicomplexa: Piroplasmida) has decreased markedly since the 1930 s, but may re-emerge as a consequence of climate change and changes in legislation and pasturing practices. This is a potentially serious disease, with both economical and animal welfare consequences. Therefore, there is a need to survey the distribution of B. divergens., Methods: We tested sera from 306 healthy pastured cows from 24 farms along the southern Norwegian coast by using an indirect immunofluorescence IgG antibody test (IFAT). Fractions of seropositive cows were compared by calculating 95% CI., Results: The results of this test showed that 27% of the sera were positive for B. divergens antibodies. The fraction of antibody-positive sera that we detected showed a two-humped distribution, with a high fraction of positives being found in municipalities in the western and eastern parts of the study area, while the municipalities between these areas had few or no positive serum samples., Conclusions: Neither the farmers' observations nor the Norwegian Dairy Herd Recording System give an adequate picture of the distribution of bovine babesiosis. Serological testing of cows by using IFAT is a convenient way of screening for the presence of B. divergens in an area.

Aims: The aim of this paper is to explore experiences of being diagnosed with tuberculosis (TB) among immigrants in Norway, with a view to factors associated with diagnostic delay., Methods: A qualitative study was conducted among 22 participants diagnosed with TB who originated from Somalia or Ethiopia., Results: One-third of the participants reported less than 2 months from onset of symptoms to treatment were initiated. The factors associated with little delay included a medical history that gave suspicion of TB, presenting with typical TB symptoms, or being screened for TB at arrival. Two-thirds of the participants told about extensive diagnostic processes. Persistent cough not accompanied by symptoms such as: weight loss and weakness; mild, diffuse, atypical, and/or intermittent symptoms; and a sense of not being a likely victim of TB could delay patients' first initiative to seek help. Participants experienced that the diagnostic process in the health services could endure for months, even years. The diagnosis could be difficult to confirm, but health professionals appeared to have difficulties with associating their symptoms with TB. This resulted in delays in initiating diagnostic tests for TB, especially in cases of extra-pulmonary TB., Conclusions: Public health efforts to increase awareness about TB transmission, its diversity in manifestations, and its progression from latent to active disease, may decrease patient delay. An increased awareness among health professionals about typical and atypical symptoms of TB, aspects of the patient's history, and being aware and sensitive to patients' own interpretation of symptoms may reduce diagnostic delay in the health services.

Background: To investigate how the risk of active tuberculosis disease is influenced by time since original infection and to determine whether the risk of reactivation of tuberculosis increases or decreases with age., Methods: Cohort analysis of data for the separate ten year birth cohorts of 1876-1885 to 1959-1968 obtained from Statistics Norway and the National Tuberculosis Registry. These data were used to calculate the rates and the changes in the rates of bacillary (or active) tuberculosis. Data on bacillary tuberculosis for adult (20+) age groups were obtained from the National Tuberculosis Registry and Statistics Norway from 1946 to 1974. Most cases during this period arose due to reactivation of remote infection. Participants in this part of the analysis were all reported active tuberculosis cases in Norway from 1946 to 1974 as recorded in the National Tuberculosis Registry., Results: Tuberculosis decreased at a relatively steady rate when following individual birth cohorts, but with a tendency of slower decline as time passed since infection. A mean estimate of this rate of decline was 57% in a 10 year period., Conclusions: The risk of reactivation of latent tuberculosis decreases with age. This decline may reflect the rate at which latent tuberculosis is eliminated from a population with minimal transmission of tubercle bacilli. A model for risk of developing active tuberculosis as a function of time since infection shows that the rate at which tuberculosis can be eliminated from a society can be quite substantial if new infections are effectively prevented. The findings clearly indicate that preventative measures against transmission of tuberculosis will be the most effective. These results also suggest that the total population harbouring live tubercle bacilli and consequently the future projection for increased incidence of tuberculosis in the world is probably overestimated.

Background: We intended to assess the risk for health care workers (HCWs) of acquiring M. tuberculosis infection after exposure to patients with sputum-smear positive pulmonary tuberculosis at three University Hospitals (Ullevål, Akershus, and Haukeland) in Norway., Methods: We tested 155 exposed health care workers and 48 healthy controls both with a tuberculin skin test (Mantoux) and the T-SPOT.TB test, a recently developed interferon-gamma release assays based on the M. tuberculosis-specific ESAT-6 and CFP10 antigens, to investigate if this test might improve infection control measures., Results: Among the 155 exposed HCWs tested in this study, 27 individuals were defined as newly infected cases by TST after recent exposure, while only 3 of these had a positive T-SPOT.TB test. The number of T-SPOT.TB positives represents 11% of the individuals defined as recently infected by TST after exposure (3/27) and 2% of the total number of exposed people tested (3/155). In addition, 15 individuals had been previously defined as infected by TST before exposure of whom 2 subjects were T-SPOT.TB positive. All individuals detected as T-SPOT.TB positive belonged to the TST positive group (> 15 mm), and the percentage concordance between T-SPOT.TB and TST, including both previously and newly infected subjects, was 12% (5/42). The 48 control participants used in the study were all T-SPOT.TB negative, but 3 of these subjects were TST positive., Conclusion: Our data indicate that the frequency of latent TB in the total cohort of HCWs is 3%, whereas the rate of transmission of TB to exposed individuals is approximately 2% and occurs through exposure periods of short duration. Thus, the risk of TB transmission to HCWs following TB exposure in a hospital setting in Norway is low, and improved screening approaches will benefit from the application of specific interferon-gamma release assays.