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Background: In order to improve preparedness and response capacities in the European Union, a good overview of capacities at both country and union level is needed. The International Health Regulations (2005) Monitoring and Evaluation framework aims to assess capacities in countries. It includes semi-quantitative tools such as the State Parties Annual Report (SPAR) and the Joint External Evaluation (JEE). After Action Reviews (AAR) and Simulation Exercises (SimEx) were included to identify weaknesses in the functionality of capacities which are not addressed by SPAR and JEE. This study presents an analysis of the use of these tools on a regional level, in Europe. It aims to identify their added value by comparing them to standardised monitoring tools and lessons learned from COVID-19, and considers ways to improve their use in assessing capacities in the EU.Methods: We included 17 SimEx and 2 AAR organized by the European Commission between 2005 and 2018. We categorized a total of 357 recommendations according to the IHR (2005) core capacities they addressed and their target audience. We analysed data using language analysis software. Recommendations to countries were compared to SPAR and JEE indicators. Recommendations to EU agencies were compared to the current mandates of the EU agencies, and to lessons learnt during COVID-19.Results: Of all the extracted recommendations, 59% targeted EU agencies, 18% targeted countries, and 16% targeted both. Recommendations mainly addressed areas of IHR coordination (C2), heath emergency management (C7) and risk communication (C10), and not low scoring areas. Recommendations complement SPAR indicators by identifying gaps in functionality. Eight out of ten early lessons learnt during the Covid-19 pandemic had been raised earlier as recommendations from exercises. Exercise reports assessed did not include or result in action plans for implementation, but COVID-19 has accelerated implementation of some recommendations.Conclusion: SimEx/AAR provide valuable insight into public health preparedness at EU level, as they assess functionality of response mechanisms, point out gaps, and provide training and awareness for participants, who often have key roles in public health emergencies. Better follow-up and implementation of recommendations can improve the regional preparedness for international public health incidents.

In the light of the recent findings of the tapeworm Echinococcus multilocularis (EM) in four red foxes from three different locations in Sweden, the Norwegian Scientific Committee for Food Safety (Vitenskapskomiteen; VKM), Panel of Biological Hazards (Faggruppe hygiene og smittestoffer) took the initiative to undertake a risk assessment regarding the probability of this parasite being introduced to mainland Norway and thus becoming a threat to public health in the country. EM is a small tapeworm that resides in the intestine of carnivores (e.g. foxes, dogs) that function as final hosts for the adult tapeworm. The infection here gives few or no symptoms. Adult tapeworms produce eggs that are released in the faeces of the carnivores and may be ingested by mammals, usually rodents or lagomorphs1, which act as intermediate hosts. In the intermediate hosts, the larval form of the tapeworm produces cysts, predominantly in the liver, where they proliferate and may invade the surrounding tissues. If the infected intermediate host is eaten by a susceptible final host, the adult tapeworm develops in the intestine and the lifecycle is completed. EM is of public health significance as humans may act as accidental intermediate hosts if they ingest eggs, either through contaminated foods or water, or from contact with infected final hosts (dogs, foxes) or their faeces. In untreated patients the disease is often fatal (10 year survival rate of 29 %), and in treated patients the 10 year survival rate is 80 %. The anthelmintic treatment is long-term (for several years, possibly life-long) and expensive. Liver transplantation may be required. Conclusions: Based on the fact that EM is endemic in many European countries, that the incidence in endemic countries is increasing, and that the areas of endemicity are expanding it seems likely that EM will be imported into Norway at some point, perhaps within the next 10 years. Given the high numbers of pets crossing the border between Sweden and Norway and the paucity of checks regarding compliance with treatment legislation, this seems to be a likely route of entry of EM to Norway, should this occur. Introduction of checks may reduce this likelihood. Under the current monitoring conditions, VKM find it less likely that EM will be detected upon the first introduction to Norway. EM will probably only be detected once the prevalence in foxes is greater than 1%. The red fox population size is estimated to be between 70 000 to 120 000 animals. This means between 700 to 1200 red foxes would need to be infected before EM infection is likely to be detected under the current monitoring program. If EM is identified early enough after introduction, then it might be possible to avoid the establishment of EM in Norway and/or to limit the region of endemicity. This is dependent on optimal detection techniques and sufficient monitoring. VKM considers that it is unlikely that EM will be imported to Norway via contaminated produce (berries, fruits and mushrooms). Norway’s strong ‘outdoor’ culture, in which hunting, camping, berry-picking and other outdoor activities play a significant role, may place the Norwegian population at greater likelihood of contracting EM than populations in other European countries. However, it should be noted that even in countries with endemic EM, human echinococcosis is, apparently, relatively rare.

On 10. March 2006 , The Norwegian Food Safety Authority (Mattilsynet) decided that, on the basis of VKM’s previous risk assessment (2005), Nutramigen 1 with Lactobacillus rhamnosus GG (LGG) could not be marketed in Norway as medical foods for infants (0-4 months). In addition, The Norwegian Food Safety Authority (Mattilsynet) decided (08. November 2006) to withdraw permission for marketing of Nutramigen 2 with LGG, which is a milk supplement for infants aged between 4 and 6 months, with cow’s milk and soy protein allergy. On 13. December 2006, Mead Johnson Nutritionals appealed against this decision from The Norwegian Food Safety Authority (Mattilsynet). The Norwegian Food Safety Authority forwarded the appeal from the companies, asked the VKM Panel on biological hazards and the VKM Panel on nutrition, dietetic products, novel food and allergy, for a new risk assessment including the new data provided in the appeal. LGG is one of the most studied probiotic strains. Lactic acid produced by LGG in the human gut results in a decrease in faecal pH, which in turn inhibits colonisation by potentially pathogenic bacteria. Short-term beneficial effects from administration of LGG to infants and young children with infectious diarrhoea have been reported in a number of studies, but a prophylactic effect on diarrhoea has not been documented. Furthermore, whilst some studies have reported a prophylactic, or even a curative, effect of LGG on atopic eczema in young children, more recent studies do not report such effects. Some even suggest an increased incidence of allergic sensitization in children receiving LGG supplemented formula at an early age. There are no published data that demonstrate long-term clinical benefits of infant formula supplemented with LGG for children between 4 months and 3 years, although no immediate deleterious effects of LGG have been found. Possible long-term effects of LGG on intestinal colonisation, and its effects on long-term gastrointestinal and immune functions, are not known. LGG, as an ingredient in infant formula and baby foods, is intended for daily use in the target group, and not for short-term, specific treatment. Furthermore, the targeted consumer group includes children below the age of twelve months. These two aspects demand particular consideration with regard to the unknown effects of long-term treatment with large doses of live bacteria on the ecology of the microbiota of the gastrointestinal tract and on the immune system. Neither of these systems is fully matured in infants and small children, and therefore may be particularly susceptible. There is no documented prophylactic effect of LGG on any disease in children. The effect of treatment with LGG-supplemented formula in small children is questionable, except for a documented short-term effect on infectious diarrhoea. Panel on Biological Hazards and Panel on nutrition, dietetic products, novel food and allergy at the Norwegian Scientific Committee for Food Safety find that the data available are not sufficient to support the suggested beneficial effects, or the safety, of LGG in infant formula and baby foods for children aged between 4 months and 3 years, when the products are intended for daily use.

This nationwide registry data study from Norway assesses the secondary attack rate of SARS-CoV-2 variants Delta and Omicron in an effort to estimate the transmissibility of the Omicron variant.

The Norwegian Scientific Committee for Food Safety (VKM) has appointed an ad hoc-group of experts to answer a request from the Norwegian Food Safety Authority regarding benefit and risk assessment of Lactobacillus paracasei ssp. paracasei F19 (F19) in processed cerealbased baby foods intended for small children 1-3 years. This assessment is based on the literature provided by the notifier as well as that found by a MEDLINE search. A notification regarding two products of processed cereal-based baby foods (hereafter called cereals), intended for small children and supplemented with the bacterium F19 initiated this work. A daily supply of a monoculture of a particular bacterial strain in large quantities to an age group without a fully established intestinal flora, may have unknown adverse effects. There are however, to our knowledge, no studies investigating possible short or long term adverse health effects of F19 in processed cereal-based baby food given to children 13 months onwards. The documentation and information provided by the notifier regarding the genetic stability of F19 in the two products during processing and storage, is considered insufficient and does not allow any conclusions to be drawn. Moreover, the documentation obtained is not conclusive regarding the antibiotic resistance pattern of the bacterial strain used in the products in question, as the information on different antibiotics is partly inconsistent. The information about specific localization (chromosomal, plasmid) of the resistance genes is not sufficient. Studies demonstrate that F19, as well as other bacterial strains considered probiotic, is able to “crosstalk” with enterocytes in mice and that the result of the “crosstalk” depends upon the microbiota present. Whether F19 has a similar “crosstalk-profile” in humans is unknown. However, as the strain is originally of human origin, it seems reasonable to assume that such “crosstalk” may occur. Thus, before giving F19 daily for months and years, it seems reasonable to ask for additional molecular and physiological studies to unravel the functional impact of possible changes in genetic expression in children. Lactobacillus infections do occasionally occur, mainly as bacteremia, endocarditis and localized infections (e.g. abscesses, peritonitis, and meningitis) in patients with severe underlying diseases. Most of them are elderly, but children are not excluded. The species most often isolated are L. casei and L. rhamnosus, followed by L. paracasei. The increasing use of immunosuppressive therapy and broad spectrum antibiotics which are ineffective against Lactobacillus, might increase the importance of these bacteria as possible pathogens. In order to be able to draw any conclusions regarding beneficial effects of F19, there is a need for randomized placebo-controlled studies in larger populations and in the relevant age group. According to EFSA, Lactobacillus paracasei ssp. paracasei F19 is sufficiently characterized. The documentation provided is, however, not sufficient to claim positive health effects and thus F19 is not proven to be probiotic. There are no published dose-response studies of F19 in children, neither regarding survival of F19 in the gastrointestinal tract, nor possible negative health effects. Thus the potential for negative health effects as e.g. spreading of antimicrobial resistance or unfavourable impact on the genetic expression in children related to the frequency and/or dose of a monoculture of F19 cannot be assessed.

The Norwegian Scientific Committee for Food Safety (VKM) has appointed an ad hoc-group of experts to answer a request from the Norwegian Food Safety Authority regarding benefit and risk assessment of B. lactis Bb12 in baby foods focusing on the age groups 4-6 months, 612 months and 1-3 years. This assessment is based on the literature provided by the notifier as well as that found by a MEDLINE search. An notification for use of processed cereal-based baby foods (from now on called cereals) intended for infants and small children supplemented with the microorganism Bifidobacterium lactis (B. lactis) Bb12 in Norway initiated this work. Studies of potential hazards and positive health effects from cereals containing B. lactis Bb12 intended for infants and young children have not been reported in the available literature. However, reports on safety of and positive health effects from infant and follow on formula supplemented with B. lactis Bb12 are available and have been assessed by VKM. In most of these clinical studies B. lactis Bb12 was administered in combination with other probiotic strains. Clinical studies report no serious adverse events of infant formula supplemented with B. lactis Bb12. The effect of long term daily consumption of such supplemented formula by the actual age groups is not known. A few studies have demonstrated some effect of supplementing baby food with probiotics, including B. lactis Bb12, on diarrhoea and atopic eczema while other studies do not show such effects. Thus, the scientific evidence for a favourable effect of supplementing formula or solid food with B. lactis Bb12, is weak and in some cases lacking. There are no studies demonstrating a positive effect of cereals supplemented with B. lactis Bb12 intended for infants and small children. Several health claims related to probiotics have been assessed by EFSA, including claims on reduction of gastro-intestinal discomfort, normal functioning of the alimentary tract, building of the natural intestinal barrier, improvement of the general immunity, mental and cognitive developments of children and immune system of children during growth. In the opinions so far, EFSA has concluded that a cause and effect relationship has not been established between the consumption of the probiotic containing products and the claimed effect. None of the products assessed so far contained B. lactis Bb12 (1 November 2009). Commercially produced cereals are frequent given to infants and small children in Norway from an early age and this is particularly important for the establishment of the intestinal bacterial flora and the development of the intestinal mucosal immune system. According to the notifier, one portion (25gram) of the cereal powder contains 1 x 109 B. lactis Bb12 in monoculture. Taking into consideration that the daily intake is often greater than one portion of cereals, even in infants below 6 months of age, this would represent a daily intake of 1-2 x 109 cfu B. lactis Bb12 for an infant 4-6 months and even more in infants above 6 months. If a considerable amount of the B. lactis Bb12 survives the transport to the small intestine, it would represent a dominating and monocultural supply, often several times a day, to the small intestine. The immaturity and vulnerability of the intestinal microbiota and the immune system makes the two lowest age groups, 4 – 6 and 6 – 12 months, at the highest risk of unwanted health effects due to the daily intake of probiotics.

Understanding the rapid epidemic growth of the novel SARS-CoV-2 Omicron variant is critical for public health management. We compared the secondary attack rate (SAR) of the Omicron and Delta variants in households using Norwegian contact tracing data from December 2021 to January 2022. Omicron SAR was higher (51%) than Delta (36%), with a relative risk (RR) of 1.41 (95% CI 1.27–1.56). We observed increased susceptibility to Omicron infection in household contacts compared to Delta independent of vaccination status; however, considering booster vaccinated contacts, the mean SAR was lower for both variants. We found increased Omicron transmissibility in all vaccination groups of primary cases, except partially vaccinated, compared to Delta. In particular, Omicron SAR for boosted primary cases was high, 46% vs 11% for Delta (RR 4.34; 95% CI 1.52–25.16). In conclusion, booster doses decrease the infection risk of Delta and Omicron but have limited effect in preventing Omicron transmission.

We included 39,524 COVID-19 Omicron and 51,481 Delta cases reported in Norway from December 2021 to January 2022. We estimated a 73% reduced risk of hospitalisation (adjusted hazard ratio: 0.27; 95% confidence interval: 0.20–0.36) for Omicron compared with Delta. Compared with unvaccinated groups, Omicron cases who had completed primary two-dose vaccination 7–179 days before diagnosis had a lower reduced risk than Delta (66% vs 93%). People vaccinated with three doses had a similar risk reduction (86% vs 88%).

Objectives To estimate the risk of hospitalization among reported cases of the Delta variant of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) compared with the Alpha variant in Norway, and the risk of hospitalization by vaccination status. Methods A cohort study was conducted on laboratory-confirmed cases of SARS-CoV-2 in Norway, diagnosed between 3 May and 15 August 2021. Adjusted risk ratios (aRR) with 95% confidence intervals (CI) were calculated using multi-variable log-binomial regression, accounting for variant, vaccination status, demographic characteristics, week of sampling and underlying comorbidities. Results In total, 7977 cases of the Delta variant and 12,078 cases of the Alpha variant were included in this study. Overall, 347 (1.7%) cases were hospitalized. The aRR of hospitalization for the Delta variant compared with the Alpha variant was 0.97 (95% CI 0.76–1.23). Partially vaccinated cases had a 72% reduced risk of hospitalization (95% CI 59–82%), and fully vaccinated cases had a 76% reduced risk of hospitalization (95% CI 61–85%) compared with unvaccinated cases. Conclusions No difference was found between the risk of hospitalization for Delta cases and Alpha cases in Norway. The results of this study support the notion that partially and fully vaccinated cases are highly protected against hospitalization with coronavirus disease 2019. publishedVersion

Background The occupational risk of COVID-19 may be different in the first versus second epidemic wave. Aim To study whether employees in occupations that typically entail close contact with others were at higher risk of SARS-CoV-2 infection and COVID-19-related hospitalisation during the first and second epidemic wave before and after 18 July 2020, in Norway. Methods We included individuals in occupations working with patients, children, students, or customers using Standard Classification of Occupations (ISCO-08) codes. We compared residents (3,559,694 on 1 January 2020) in such occupations aged 20–70 years (mean: 44.1; standard deviation: 14.3 years; 51% men) to age-matched individuals in other professions using logistic regression adjusted for age, sex, birth country and marital status. Results Nurses, physicians, dentists and physiotherapists had 2–3.5 times the odds of COVID-19 during the first wave when compared with others of working age. In the second wave, bartenders, waiters, food counter attendants, transport conductors, travel stewards, childcare workers, preschool and primary school teachers had ca 1.25–2 times the odds of infection. Bus, tram and taxi drivers had an increased odds of infection in both waves (odds ratio: 1.2–2.1). Occupation was of limited relevance for the odds of severe infection, here studied as hospitalisation with the disease. Conclusion Our findings from the entire Norwegian population may be of relevance to national and regional authorities in handling the epidemic. Also, we provide a knowledge foundation for more targeted future studies of lockdowns and disease control measures.

ObjectivesTo estimate the risk of hospitalisation among reported cases of the Delta-variant of SARS-CoV-2 compared to the Alpha variant in Norway. We also estimated the risk of hospitalisation by vaccination status.MethodsWe conducted a cohort study on laboratory-confirmed cases of SARS-CoV-2 in Norway, diagnosed between 3 May and 15 August 2021. We calculated adjusted risk ratios (aRR) with 95% confidence intervals (CIs) using multivariable binomial regression, accounting for variant, vaccination status, demographic characteristics, week of sampling and underlying comorbidities.ResultsWe included 7,977 cases of Delta and 12,078 cases of Alpha. Overall, 347 (1.7%) cases were hospitalised. The aRR of hospitalisation for Delta compared to Alpha was 0.97 (95%CI 0.76–1.23). Partially vaccinated cases had a 72% reduced risk of hospitalisation (95%CI 59%–82%), and fully vaccinated cases had a 76% reduced risk (95%CI 61%–85%), compared to unvaccinated cases.ConclusionsWe found no difference in the risk of hospitalisation for Delta cases compared to Alpha cases in Norway. Further research from a wide variety of settings is needed to better understand the association between the Delta variant and severe disease. Our results support the notion that partially and fully vaccinated persons are highly protected against hospitalisation with COVID-19.HighlightsThe SARS-CoV-2 Delta variant has dominated in Norway since July 2021There was no difference in the risk of hospitalisation for Delta cases compared to AlphaPartially and fully vaccinated cases had >70% decreased risk of hospitalisation

BackgroundThe SARS-CoV-2 variant of concern (VOC) B.1.1.7 has spread worldwide and has been associated with increased risk of severe disease. Studies on patient trajectories and outcomes among hospitalised patients infected with B.1.1.7 are essential for hospital capacity planning.MethodsUsing linked individual-level data from national registries, we conducted a cohort study on cases of SARS-CoV-2 in Norway hospitalised between 21 December 2020 and 25 April 2021. We calculated adjusted hazard ratios using survival analysis to examine the association between B.1.1.7 and time from symptom onset to hospitalisation, and length of stay (LoS) in hospital and an intensive care unit compared to non-VOC. We calculated adjusted odds ratios using logistic regression to examine the association between B.1.1.7 and mortality (up to 30 days post discharge) compared to non-VOC.ResultsWe included 946 B.1.1.7 patients and 157 non-VOC. The crude median time from symptom onset to hospitalisation was 8 days (IQR: 5–10) for B.1.1.7 and 8 days (IQR: 4–11) for non-VOC. The crude median LoS in hospital was 5.0 days (IQR: 2.6–10.0) for B.1.1.7 patients and 5.1 days (IQR: 2.5–9.9) for non-VOC. Fifty-four (6%) B.1.1.7 patients died, compared to 14 (9%) non-VOC. There was no difference in the unadjusted or adjusted estimates of our outcome measures for B.1.1.7 and non-VOC patients.ConclusionsB.1.1.7 does not appear to influence hospitalised patient trajectories, compared to non-VOC. These findings, along with the success of ongoing vaccination programmes, are encouraging for ongoing capacity planning in the hospital sector.

Summary Aim The aim of this study was, for the first time, to describe in detail the epidemiology and impact of norovirus outbreaks in healthcare institituions (HCIs) in Norway to identify areas which may improve outbreak response. Methods An analysis of all reported norovirus outbreaks in hospitals and long-term-care facilities (LTCFs) was carried out from week 34, 2005 to week 33, 2018. Seasonality, symptoms and number of cases among personnel and patients were described. Findings A total of 20,544 cases, including 7044 healthcare personnel were reported in 965 outbreaks; 740 from LTCFs and 225 from hospitals. Median number of cases per outbreak was 15, interquartile range (IQR) 8–25 in LTCF; and 17, IQR 10–28 in hospitals. All regions reported outbreaks, with one-third of the municipalities having at least one outbreak in LTCFs during the study period. The start of the outbreak season happened almost four weeks earlier in hospitals than in LTCFs. The estimated average number of working days lost for healthcare personnel per year ranged from 1590 to 1944. Conclusions Norovirus outbreaks in Norwegian HCIs appears to have a substantial impact on both hospital and LTCFs all over Norway, especially during the winter months. That up to half of all cases were healthcare professionals emphasizes a need for further focus on infection control. Our results suggest that hospitals, affected first, could alert LTCFs in the area in order to prevent further outbreaks.

The Norwegian department of agriculture decided to re-evaluate the Regulation No. 951 of 4 July 2003 on fertilizers and soil improvers of organic origin. The Norwegian Food Safety Authority (NFSA) requested VKM for a statement on the use of manure from farms where grey water and human waste (sewage) is disposed of directly to the farm manure cellar. Consideration was given to differences in risk according to the types of domestic wastewater, the species of animal from which the manure derived, the extent and type of sanitary facilities, the crops to which the amended manure is applied, and the effects of storage on infection risk. According to current legislation, sewage sludge cannot be spread on land where vegetables, potatoes, berries or fruit are grown. Furthermore, sewage cannot be spread on meadows or used for horticultural purposes. In private gardens, parks, playgrounds and similar residential areas, sewage may be used only as a component in a fertiliser, and not applied at the surface. Use of sewage as a fertilizer for the cultivation of grains is permitted. Sewage can also be used when establishing vegetation along roads and embankments. VKM concludes that manure cellars, to which wastewater, from private household use, and sewage from toilets in the outbuildings are drained, may contain pathogens from humans, in addition to those pathogens originating from animals. The quantity and species of pathogens in this sewage-amended manure would reflect the species and prevalence of pathogens in the population using the facilities. Although the prevalence of intestinal pathogens in the Norwegian human population is relatively low, it should be noted that farms in Norway often provide tourist accommodation, camping facilities, and may house migrant short-term employees during the summer season during which labour requirements are increased. Thus non-Norwegian populations may also use toilet facilities on these farms, and thus when considering the risk of human pathogens, consideration should also be given to people from countries where the prevalence of such pathogens may be higher. As many viruses and parasites are host-specific, the risk of contamination of produce with human pathogens from such manure is likely to be greater than from manure which has not been amended with untreated sewage. Pathogen survival is affected by storage, but it should be noted that some pathogens have robust and environmentally resistant transmission stages (e.g. parasite oocysts, cysts and eggs), a proportion of which may survive for prolonged periods in stored manure.

The coronavirus disease 2019 (COVID-19) response in most countries has relied on testing, isolation, contact tracing, and quarantine (TITQ), which is labor- and time-consuming. Therefore, several countries worldwide launched Bluetooth-based apps as supplementary tools. The aim of using contact tracing apps is to rapidly notify people about their possible exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and thus make the process of TITQ more efficient, especially upon exposure in public places. We evaluated the Norwegian Google Apple exposure notification (GAEN)-based contact tracing app Smittestopp v2 under relevant “real-life” test scenarios. We used a total of 40 devices, representing six different brands, and compared two different exposure configurations, experimented with different time thresholds and weights of the Bluetooth attenuation levels (buckets), and calculated the true notification rates among close contacts (≤2 m and ≥15 min) and false notification of sporadic contacts. In addition, we assessed the impact of using different operating systems and locations of the phone (hand/pocket). The best configuration tested to trigger exposure notification resulted in the correct notification of 80% of the true close contacts and incorrect notification of 34% of the sporadic contacts. Among those who incorrectly received notifications, most (67%) were within 2 m but the duration of contact was per se, considered as “close contacts.” Lower sensitivity was observed when using the iOS operating systems or carrying the phone in the pocket instead of in the hand. The results of this study were used to improve and evaluate the performance of the Norwegian contact-tracing app Smittestopp.

BackgroundAs in other countries, the coronavirus disease 2019 (COVID-19) pandemic has affected Norway’s immigrant population disproportionately with significantly higher infection rates and hospitalizations. The reasons for this are uncertain.MethodsThrough the national emergency preparedness register, BeredtC19, we have studied laboratory-confirmed infections with SARS-CoV-2 and related hospitalizations in the entire Norwegian population, by birth-country background for the period 15 June 2020 – 31 March 2021, excluding the first-wave due to limited test capacity and restrictive test criteria. Straightforward linkage of individual-level data allowed adjustment for demographics, socioeconomic factors (occupation, household crowding, education, and household income), and underlying medical risk for severe COVID-19 in regression models.ResultsThe sample comprised 5.49 million persons, of which 0.91 million born outside of Norway, 82 532 confirmed cases, and 3088 hospitalizations. Confirmed infections in this period (per 100 000): foreign-born 3140, Norwegian-born with foreign-born parents 4799, Norwegian-born with Norwegian-born parent(s) 1011. Hospitalizations (per 100 000): foreign-born 147, Norwegian-born with foreign-born parents 47, Norwegian-born with Norwegian-born parent(s) 37. The addition of socioeconomic and medical factors to the base-model (age, sex, municipality of residence) attenuated excess infection rates by 12.0% and hospitalizations by 3.8% among foreign-born, and 10.9% and 46.2% respectively among Norwegian-born with foreign parents, compared to Norwegian-born with Norwegian-born parent(s).ConclusionThere were large differences in infection rates and hospitalizations by country background, and these do not appear to be fully explained by socioeconomic and medical factors. Our results may have implications for health policy, including the targeting of mitigation strategies.

We use data from contact tracing in Oslo, Norway, to estimate the new SARS-CoV-2 B.1.1.7 lineage’s relative transmissibility. Within households, we find an increase in the secondary attack rate by 60% (20% 114%) compared to other variants. In general, we find a significant increase in the estimated reproduction number of 24% (95% CI 0% - 52%), or an absolute increase of 0.19 compared to other variants.

BACKGROUND: Information about the contagiousness of new SARS-CoV-2 variants, including the alpha lineage, and how they spread in various locations is essential. Country-specific estimates are needed because local interventions influence transmissibility. METHODS: We analysed contact tracing data from Oslo municipality, reported from January through February 2021, when the alpha lineage became predominant in Norway and estimated the relative transmissibility of the alpha lineage with the use of Poisson regression. RESULTS: Within households, we found an increase in the secondary attack rate by 60% (95% CI 20-114%) among cases infected with the alpha lineage compared to other variants; including all close contacts, the relative increase in the secondary attack rate was 24% (95% CI -6%-43%). There was a significantly higher risk of infecting household members in index cases aged 40-59 years who were infected with the alpha lineage; we found no association between transmission and household size. Overall, including all close contacts, we found that the reproduction number among cases with the alpha lineage was increased by 24% (95% CI 0%-52%), corresponding to an absolute increase of 0.19, compared to the group of index cases infected with other variants. CONCLUSION: Our study suggests that households are the primary locations for rapid transmission of the new lineage alpha.

An intense debate on school closures to control the COVID-19 pandemic is ongoing in Europe. We prospectively examined transmission of SARS-CoV-2 from confirmed paediatric cases in Norwegian primary schools between August and November 2020. All in-school contacts were systematically tested twice during their quarantine period. With preventive measures implemented in schools, we found minimal child-to-child (0.9%, 2/234) and child-to-adult (1.7%, 1/58) transmission, supporting that under 14 year olds are not the drivers of SARS-CoV-2 transmission.

Background Waterborne outbreaks are still a risk in high-income countries, and their early detection is crucial to limit their societal consequences. Although syndromic surveillance is widely used for the purpose of detecting outbreaks days earlier than traditional surveillance systems, evidence of the effectiveness of such systems is lacking. Thus, our objective was to conduct a systematic review of the effectiveness of syndromic surveillance to detect waterborne outbreaks. Method We searched the Cochrane Library, Medline/PubMed, EMBASE, Scopus, and Web of Science for relevant published articles using a combination of the keywords ‘drinking water’, ‘surveillance’, and ‘waterborne disease’ for the period of 1990 to 2018. The references lists of the identified articles for full-text record assessment were screened, and searches in Google Scholar using the same key words were conducted. We assessed the risk of bias in the included articles using the ROBINS-I tool and PRECEPT for the cumulative body of evidence. Results From the 1959 articles identified, we reviewed 52 articles, of which 18 met the eligibility criteria. Twelve were descriptive/analytical studies, whereas six were simulation studies. There is no clear evidence for syndromic surveillance in terms of the ability to detect waterborne outbreaks (low sensitivity and high specificity). However, one simulation study implied that multiple sources of signals combined with spatial information may increase the timeliness in detecting a waterborne outbreak and reduce false alarms. Conclusion This review demonstrates that there is no conclusive evidence on the effectiveness of syndromic surveillance for the detection of waterborne outbreaks, thus suggesting the need to focus on primary prevention measures to reduce the risk of waterborne outbreaks. Future studies should investigate methods for combining health and environmental data with an assessment of needed financial and human resources for implementing such surveillance systems. In addition, a more critical thematic narrative synthesis on the most promising sources of data, and an assessment of the basis for arguments that joint analysis of different data or dimensions of data (e.g. spatial and temporal) might perform better, should be carried out. Trial registration PROSPERO: International prospective register of systematic reviews. 2019. CRD42019122332.

IntroductionSince their emergence, SARS-CoV-2 variants of concern (VOC) B.1.1.7 and B.1.351 have spread worldwide. We estimated the risk of hospitalisation and admission to an intensive care unit (ICU) for infections with B.1.1.7 and B.1.351 in Norway, compared to infections with non-VOC.Materials and methodsUsing linked individual-level data from national registries, we conducted a cohort study on laboratory-confirmed cases of SARS-CoV-2 in Norway diagnosed between 28 December 2020 and 2 May 2021. Variants were identified based on whole genome sequencing, partial sequencing by Sanger sequencing or PCR screening for selected targets. The outcome was hospitalisation or ICU admission. We calculated adjusted risk ratios (aRR) with 95% confidence intervals (CIs) using multivariable binomial regression to examine the association between SARS-CoV-2 variants B.1.1.7 and B.1.351 with i) hospital admission and ii) ICU admission compared to non-VOC.ResultsWe included 23,169 cases of B.1.1.7, 548 B.1.351 and 4,584 non-VOC. Overall, 1,017 cases were hospitalised (3.6%) and 206 admitted to ICU (0.7%). B.1.1.7 was associated with a 1.9-fold increased risk of hospitalisation (aRR 95%CI 1.6–2.3) and a 1.8-fold increased risk of ICU admission (aRR 95%CI 1.2–2.8) compared to non-VOC. Among hospitalised cases, no difference was found in the risk of ICU admission between B.1.1.7 and non-VOC. B.1.351 was associated with a 2.4-fold increased risk of hospitalisation (aRR 95%CI 1.7–3.3) and a 2.7-fold increased risk of ICU admission (aRR 95%CI 1.2–6.5) compared to non-VOC.DiscussionOur findings add to the growing evidence of a higher risk of severe disease among persons infected with B.1.1.7 or B.1.351. This highlights the importance of prevention and control measures to reduce transmission of these VOC in society, particularly ongoing vaccination programmes, and preparedness plans for hospital surge capacity.

In late November 2021, an outbreak of Omicron SARS-CoV-2 following a Christmas party with 117 attendees was detected in Oslo, Norway. We observed an attack rate of 74% and most cases developed symptoms. As at 13 December, none have been hospitalised. Most participants were 30–50 years old. Ninety-six percent of them were fully vaccinated. These findings corroborate reports that the Omicron variant may be more transmissible, and that vaccination may be less effective in preventing infection compared with Delta.

The role of children in the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in schools has been a topic of controversy. In this study among school contacts of SARS-CoV-2 positive children in 43 contact-investigations, we investigated SARS-CoV-2 transmission in Norway, August 2020–May 2021. All participants were tested twice within seven to ten days, using SARS-CoV-2 PCR on home-sampled saliva. Positive samples were whole genome sequenced. Among the 559 child contacts, eight tested positive (1.4%, 95% CI 0.62–2.80), with no significant difference between primary (1.0%, 95% CI 0.27–2.53) and secondary schools (2.6%, 95% CI 0.70–6.39), p = 0.229, nor by viral strain, non-Alpha (1.4%, 95% CI 0.50–2.94) and Alpha variant (B.1.1.7) (1.7%, 95% CI 0.21–5.99), p = 0.665. One adult contact (1/100) tested positive. In 34 index cases, we detected 13 different SARS-CoV-2 Pango lineage variants, with B.1.1.7 being most frequent. In the eight contact-investigations with SARS-CoV-2 positive contacts, four had the same sequence identity as the index, one had no relation, and three were inconclusive. With mitigation measures in place, the spread of SARS-CoV-2 from children in schools is limited. By excluding contact-investigations with adult cases known at the time of enrolment, our data provide a valid estimate on the role of children in the transmission of SARS-CoV-2 in schools.

AimTo study whether employees in occupations that typically imply close contact with other people are tested more and at higher risk of confirmed SARS-CoV-2 infection (COVID-19) and related hospitalization, in the 1st and 2nd wave of infection in Norway.MethodsIn all 3 559 694 residents of Norway on January 1st 2020 aged 20-70 (with mean [SD] age 44.1 [14.3] years and 51% men), we studied COVID-19 testing patterns sorted by occupation (using Standard Classification of Occupations [ISCO-08]). We also studied whether selected occupations had a higher risk of 1) confirmed COVID-19 and 2) hospitalization with COVID-19, compared to everyone else aged 20-70 years using logistic regression adjusted for age, sex, testing behavior, and own and maternal country of birth.ResultsOccupations with high frequency of testing (e.g. health personnel and teachers) had a low frequency of positive tests. Nurses, physicians, dentists, physiotherapists, bus/tram and taxi drivers had 1.1-4 times the odds of COVID-19 during the 1st wave, whereas bartenders, waiters, transport conductors and travel stewards had 1.1-3 times the odds of COVID-19 during the 2nd wave (when compared to everyone else). Teachers had moderately increased odds of COVID-19. Occupation may be of limited relevance for hospitalization with the disease.ConclusionStudying the entire Norwegian population using international standardized codes of occupations, our findings may be of relevance to national and regional authorities in handling the pandemic. Also, our findings provide a knowledge foundation for the more targeted future studies of lockdown, testing strategies and disease control measures.

Global climate change is predicted to alter precipitation and temperature patterns across the world, affecting a range of infectious diseases and particularly foodborne infections such as Campylobacter. In this study, we used national surveillance data to analyse the relationship between climate and campylobacteriosis in Denmark, Finland, Norway and Sweden and estimate the impact of climate changes on future disease patterns. We show that Campylobacter incidences are linked to increases in temperature and especially precipitation in the week before illness, suggesting a non-food transmission route. These four countries may experience a doubling of Campylobacter cases by the end of the 2080s, corresponding to around 6,000 excess cases per year caused only by climate changes. Considering the strong worldwide burden of campylobacteriosis, it is important to assess local and regional impacts of climate change in order to initiate timely public health management and adaptation strategies.

On 6 June 2019, the Norwegian Institute of Public Health was notified of more than 50 cases of gastroenteritis in Askøy. A reservoir in a water supply system was suspected as the source of the outbreak because of the acute onset and geographical distribution of cases. We investigated the outbreak to confirm the source, extent of the outbreak and effect of control measures. A case was defined as a person in a household served by Water Supply System A (WSS-A) who had gastroenteritis for more than 24 h between 1 and 19 June 2019. We conducted pilot interviews, a telephone survey and an SMS-based cohort study of residents served by WSS-A. System information of WSS-A was collected. Whole genome sequencing on human and environmental isolates was performed. Among 6,108 individuals, 1,573 fulfilled the case definition. Residents served by the reservoir had a 4.6× higher risk of illness than others. Campylobacter jejuni isolated from cases (n = 24) and water samples (n = 4) had identical core genome MLST profiles. Contamination through cracks in the reservoir most probably occurred during heavy rainfall. Water supply systems are susceptible to contamination, particularly to certain weather conditions. This highlights the importance of water safety planning and risk-based surveillance to mitigate risks.

Water supply systems, in particular small-scale water supply systems, are vulnerable to adverse events that may jeopardise safe drinking water. The consequences of contamination events or the failure of daily operations may be severe, affecting many people. In Norway, a 24-hour crisis advisory service was established in 2017 to provide advice on national water supplies. Competent and expert advisors from water suppliers throughout the country assist other water suppliers and individuals who may be in need of advice during an adverse event. This paper describes the establishment of this service and experiences from the first three years of its operation. Since the launch of the service, water suppliers across Norway have consulted it approximately one to two times a month for advice, in particular about contamination events and near misses. The outcomes have helped to improve guidance on water hygiene issues at the national level.

Aims: This study aimed to describe the demographic and geographic patterns of campylobacteriosis in Denmark, Finland, Norway and Sweden during 2000–2015. Methods: All Campylobacter infections notified to national authorities in the four countries during the study period were included. Background data for each notification consisted of patient age, sex, geographical location, presumed origin of infection and date of sample taken or date of sample received in the laboratory. These data were analysed in order to investigate annual trends, age group and sex patterns, as well as variations in the geographical and seasonal distribution of infections. Results: During the study period, a total of 164,001 Campylobacter infections, excluding travel-related cases, were registered, representing a mean annual incidence of 42.3 cases/100,000 population (ranging from 28.5 in Norway to 60.4 in Denmark). The incidence increased significantly from 2004 onwards in all countries, apart from Denmark. Males had higher infection rates in general. The highest incidences were observed in 0–4 year olds and those aged 20–29 years, apart from in Finland where there was no peak of infections in children aged 0–4 years. Seasonality of disease was distinct in all four countries, showing peaks of infection between July and August. In Sweden and Norway, incidences of campylobacteriosis were significantly higher in municipalities with high degrees of coastline or inland water. Conclusions: Campylobacter in the Nordic countries mostly follows known patterns with respect to demography and seasonality. Our study demonstrates new insights concerning geographical patterns of disease, highlighting possible future vulnerable population groups and locations.

In September 2017, a cluster of monophasic Salmonella Typhimurium isolates was identified at the National Reference Laboratory for Enteropathogenic Bacteria in Norway. We investigated the cluster to identify the source and implement control measures. We defined a case as a person with laboratory-confirmed salmonellosis with the outbreak strain multiple locus variable-number tandem repeat analysis type. We conducted descriptive epidemiological and environmental investigations and performed whole genome sequencing (WGS) with core and accessory genome multilocus sequence typing of all isolates from cases or the environment connected with this outbreak. We identified 21 cases, residing in 10 geographically dispersed counties, all of whom had consumed food or drinks from a café at Oslo Airport. Case distribution by date of symptom onset suggested that a point source was introduced in mid-August followed by continued environmental contamination. The incubation periods ranged 0–16 days and increased as the outbreak progressed, likely due to increasingly low-dose exposure as control measures were implemented. WGS confirmed an identical cluster type-944 in all cases and six environmental specimens from the café. Control measures, including temporary closure and kitchen refurbishment, failed to eliminate the environmental source. We recommend strengthened hygiene measures for established environmental contamination during an outbreak.

Background: Water advisories, especially those concerning boiling drinking water, are widely used to reduce risks of infection from contaminants in the water supply. Since the effectiveness of boil water advisories (BWAs) depends on public compliance, monitoring the public response to such advisories is essential for protecting human health. However, assessments of public compliance with BWAs remain sparse. Thus, this study was aimed at investigating awareness and compliance among residents who had received BWAs in Baerum municipality in Norway. Method: We conducted a cross-sectional study among 2764 residents who had received water advisories by SMS in the municipality of Baerum between January and September 2017. We analysed data from two focus group discussions and an online survey sent to all residents who had received an advisory. We condu cted descriptive analyses and calculated odds ratios (OR) using logistic regression to identify associations of compliance and awareness with demographic characteristics. Results: Of the 611 respondents, 67% reported that they had received a water advisory notificatio n. Effective compliance rate with safe drinking water practices, either by storing clean drinking water or boiling tap water, after a water outage was 72% among those who remembered receiving a notification. Compliance with safe drink ing w ater a dvisories was lower amon g men than women (OR 0.53, 95% CI 0.2 9– 0.96), but was independent of age, education and household type. The main reason for respondents ’ non-complian ce with safe water practices was that they perceived the water to be sa fe to drink after letting it flush through the tap until it became clear. Conclusions: Awareness of advisories was suboptimal among residents who had received notifications, but compliance was high. The present study highlights the need to impr ove the distribution, phrasing and content of wa ter advisor y notifications to achieve greater a warene ss and co mplian ce. Future studies should include hard-to-reach groups with adequate dat a collection approaches and examine the use of BWAs i n a national context to inform future poli cies on BWAs. Key words: Boil w ater advisori es, BWAs, Public com pliance, Water supply i nterrupti ons, Ad herence, Dri nking water, Communication, Consumer trust Compliance with water advisories after water outages in Norway