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Introduction We compared data in two national electronic health registries to evaluate and further optimise the surveillance of patients hospitalised with COVID-19 in Norway. Method We included COVID-19 patients registered in the Norwegian Patient Registry (NPR) or Norwegian Pandemic Registry (NoPaR) with admission dates between 17 February 2020 and 1 May 2022. We linked patients, identified overlapping hospitalisation periods and described the overlap between the registries. We calculated the proportion of ICD-10 diagnosis codes (from NPR) and their combinations by main cause of admission (clinically assessed as COVID-19 or other, from NoPaR), age and time. We also calculated the sensitivity and specificity of selected code combinations for representing U07.1 patients’ main cause. Results In the study period, 20,115 admissions with laboratory-confirmed COVID-19 were registered in NoPaR, and 21,030 with the ICD-10 code U07.1 in NPR. Up to late-2021 there was a 90 – 100% overlap between the registries, which thereafter gradually decreased to below 75%. The distribution of ICD-10 codes by main cause and sensitivity and specificity of selected code combinations for representing COVID-19 as main cause varied by age and time. Conclusion Changes in patient cohorts, virus characteristics and the management of COVID-19 patients in hospitals from late-2021 impacted the registration of patients in NoPaR and ICD-10 codes in NPR. Using ICD-10 codes for the surveillance of patients hospitalised due to COVID-19 requires age- and time-specific definitions, and ongoing validation to consider temporal changes in patient cohorts and virus characteristics.

Aims: Studies have suggested that some minority groups tend to have lower vaccination rates than the overall population. This study aims to examine COVID-19 vaccination rates among healthcare workers in Norway, according to immigrant background. Methods: We used individual-level, nation-wide registry data from Norway to identify all healthcare workers employed full time at 1 December 2020. We examined the relationship between country of birth and COVID-19 vaccination from December 2020 to August 2021, both crude and adjusted for, for example, age, sex, municipality of residence and detailed occupation codes in logistic regression models. Results: Among all healthcare workers in Norway, immigrants had a 9 percentage point lower vaccination rate (85%) than healthcare workers without an immigrant background (94%) at 31 August 2021. The overall vaccination rate varied by country of birth, with immigrants born in Russia (71%), Serbia (72%), Lithuania (72%), Romania (75%), Poland (76%), Eritrea (77%) and Somalia (78%) having the lowest crude vaccination rates. When we adjusted for demographics and detailed occupational codes, immigrant groups that more often worked as healthcare assistants, such as immigrants from Eritrea and Somalia, increased their vaccination rates. Conclusions: Substantial differences in vaccination rates among immigrant groups employed in the healthcare sector in Norway indicate that measures to improve vaccine uptake should focus on specific immigrant groups rather than all immigrants together. Lower vaccination rates in some immigrant groups appear to be largely driven by the occupational composition, suggesting that some of the differences in vaccine rates can be attributed to variation in vaccine access.

The aim of this study was to establish whether the universal pneumococcal vaccination for older adults in Norway is likely to be cost-effective from the perspective of the health care provider. A decision tree model developed by the Public Health Agency of Sweden was adapted to the Norwegian setting. Two cohorts, consisting of 65-year-olds and 75-year-olds grouped into vaccinated and unvaccinated, were followed over a 5-year time horizon. In the base case, the 23-valent polysaccharide vaccine (PPV23) was used while the 13-valent pneumococcal conjugate vaccine (PCV13) was included in scenario analyses only. The costs and health benefits (measured in quality adjusted life years (QALY) gained) were compared in the two cohorts between the vaccinated and unvaccinated groups. The impact of indirect effects of the vaccine, such as herd immunity and serotype replacement, were not investigated. The relative importance of change in price was assessed by performing one-way sensitivity analyses. Under base-case assumptions, the programme for the 75-year-old cohort is expected to be dominant (cost-effective) from the health care perspective at the current maximal pharmacy retail price and at 75% vaccination coverage. In comparison, for the 65-year-old cohort the cost per QALY gained is approximately NOK 601,784 (EUR 61,281) under the base-case assumptions. A reduction in the cost of the vaccine to one quarter of its current level also brings the cost per QALY gained within the acceptable ranges in a Norwegian context for both the 65- and 75-year-old cohorts. There is no exact cost-effectiveness threshold in Norway. However, introducing a vaccination programme against pneumococcal disease for 65-year-olds in Norway is likely to fall within the acceptable range while for the 75-year-old cohort the universal programme appears to be dominant (cost-effective). Cost-utility analysis of the universal pneumococcal vaccination programme for older adults in Norway

The purpose of this study was to estimate simple measures of the burden of non-invasive pneumococcal pneumonia (PnPn) hospitalisations in those aged 50 years and older (50+) in Norway. We conducted a retrospective register-based study and used discharge codes from the Norwegian Patient Register (NPR). We identified episodes of non-invasive PnPn in 2015 to 2016 and predicted its incidence from 2015 to 2019 based on the trend found in notified invasive pneumococcal disease cases. Overall, we identified 45–46 hospital episodes per 100 000 population of non-invasive PnPn in 2015 and 2016, each episode taking 6–8 days, and with increasing incidence with higher age. Among all identified PnPn episodes, 3 out of 4 were classified as non-invasive. We predicted that the monthly number of non-invasive PnPn episodes ranges from 39 [95% confidence interval (CI) 24–55] in August to 97 (95% CI 74–134) in December. No annual trend was identified. This study indicates that the burden of non-invasive PnPn hospitalisation has a substantial impact on the health and health care use of the 50+ population in Norway, despite the childhood immunisation programme. Many hospitalisations may be prevented through vaccination.

BackgroundSARS-CoV-2 vaccines show high effectiveness against infection and (severe) disease. However, few studies estimate population level vaccine effectiveness against multiple COVID-19 outcomes, by age and including homologous and heterologous vaccine regimens.MethodsUsing Cox proportional hazard models on data from 4 293 544 individuals (99% of Norwegian adults), we estimated overall, age-, and product-specific vaccine effectiveness against SARS-CoV-2 infection, hospitalisation, ICU admission and death in Norway, using data from national registries. Vaccine status was included as time-dependent variable and we adjusted for sex, pre-existing medical conditions, country of birth, county of residence, and crowded living conditions.FindingsAdjusted vaccine effectiveness among fully vaccinated is 72·1% (71·2–73·0) against SARS-CoV-2 infection, 92·9% (91·2–94·2) against hospitalisation, 95·5% (92·6–97·2) against ICU admission, and 88·0% (82·5–91·8) against death. Among partially vaccinated, the effectiveness is 24·3% (22·3–26·2) against infection and 82·7% (77·7–86·6) against hospitalisation. Vaccine effectiveness against infection is 84·7% (83·1-86·1) for heterologous mRNA vaccine regimens, 78·3% (76·8-79·7) for Spikevax (Moderna; mRNA-1273), 69·7% (68·6-70·8) for Comirnaty (Pfizer/BioNTech; BNT162b2), and 60·7% (57·5-63·6) for Vaxzevria (AstraZeneca; ChAdOx nCoV-19; AZD1222) with a mRNA dose among fully vaccinated.InterpretationWe demonstrate good protection against SARS-CoV-2 infection and severe disease in fully vaccinated, including heterologous vaccine regimens, which could facilitate rapid immunization. Partially vaccinated were less likely to get severe disease than unvaccinated, though protection against infection was not as high, which could be essential in making vaccine prioritisation policies especially when availability is limited.FundingNorwegian Institute of Public Health, Helse Bergen Health Trust

Pancreas disease (PD) is a viral disease of economic importance affecting farmed Atlantic salmon (Salmo salar L.) and rainbow trout (Oncorhyncus mykiss (Walbaum)) in the seawater phase in Ireland, Norway and Scotland. In this study we used a stochastic network-based disease spread model to better understand the role of vessel movements and nearby seaway distance on PD spread in marine farms. We used five different edge’s definitions and weights for the network construction: high-risk vessel movements, high-risk wellboat movements and high-risk nearby seaway distance at

BackgroundStudies have suggested that some minority groups tend to have lower vaccination rates than the overall population. This study aims to examine COVID-19 vaccination rates among health care workers (HCWs) in Norway, according to immigrant background.MethodsWe used individual-level, nation-wide registry data from Norway to identify all HCWs employed full-time at 1 December 2020. We examined the relationship between country of birth and COVID-19 vaccination from December 2020 to August 2021, both crude and adjusted for e.g. age, sex, municipality of residence, and detailed occupation codes in logistic regression models.ResultsAmong all HCWs in Norway, immigrants had a 9 percentage point lower vaccination rate (85%) than HCWs without an immigrant background (94%) at 31 August 2021. The overall vaccination rate varied by country of birth, with immigrants born in Russia (71%), Serbia (72%), Lithuania (72%), Romania (75%), Poland (76%), Eritrea (77%), and Somalia (78%) having the lowest crude vaccination rates. When we adjusted for demographics and detailed occupational codes, immigrant groups that more often worked as health care assistants, such as immigrants from Eritrea and Somalia, increased their vaccination rates.ConclusionSubstantial differences in vaccination rates among immigrant groups employed in the health care sector in Norway indicate that measures to improve vaccine uptake should focus specific immigrant groups rather than all immigrants together. Lower vaccination rates in some immigrant groups appears to be largely driven by the occupational composition, suggesting that some of the differences in vaccine rates can be attributed to variation in vaccine access.

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.

In 2007, Chile reported its first case of infectious salmon anemia (ISA), caused by ISA virus (ISAV), in sea-cage reared Atlantic salmon. By 2010, the ISA disease outbreak was under control, but similarly to other countries, Chile continues to occasionally detect the non-pathogenic variant of ISAV (HPR0 ISAV). The Chilean salmon industry has been including gill samples in their routine ISAV monitoring program to improve the detection of HRP0 ISAV, which provides an opportunity to better assess the distribution of HPR0 ISAV and describe its occurrence in the Chilean marine aquaculture industry. A risk and a relative risk surface map were generated for the predominant regions of the Chilean aquaculture industry, and demonstrated areas of increased risk to HPR0 ISAV for the entire surveillance period. The observed occurrence and seasonal patterns of HPR0 ISAV were similar to those previously reported in Chile and in other countries. Further, spatiotemporal cluster analysis showed that the areas with a high-risk of HPR0 ISAV changed during the surveillance period (highly prevalent and causing non-clinical transient infections), and cases in clusters were initially observed within companies, followed by neighboring farms affecting other companies. Monitoring HPR0 ISAV in marine phase salmon production highlighted possible transmission patterns within the Chilean aquaculture industry and identified higher-risk areas associated with circulating orthomyxoviruses.

Infectious salmon anaemia (ISA) is a severe disease in farmed Atlantic salmon Salmo salar that has caused epidemic outbreaks in most salmon-producing countries worldwide. The dis- ease is caused by virulent ISA virus (ISAV). Low virulent variants of the virus, characterised by a full-length sequence in the highly polymorphic region of segment 6 in the virus genome, have been reported with increasing frequencies. These variants of the virus, termed HPR0, have been proposed to be ancestors of virulent ISAV. We examined this idea through studies of the phylogeo- graphic and environmental distribution of ISAV-HPR0, as well as phylogeographic associations between virulent ISAV and ISAV-HPR0. Samples from 232 fish groups were screened for ISAV. Real-time RT-PCR was used for detection of ISAV, and the ISAV haemagglutinin esterase (HE) gene was characterised for positive samples. A Mantel test was used to test phylogeographic asso- ciations between pairs of ISAV-HPR0 HE gene sequences. A rank test was used to test associations between HE gene sequences from virulent ISAV and ISAV-HPR0. ISAV-HPR0 was detected in fish groups both in freshwater and marine environments, and in juveniles, on-grown marine salmon and broodstock salmon. Genetic and geographic distances between pairs of ISAV-HPR0 HE gene sequences were positively correlated, suggesting that the population of ISAV-HPR0 is geograph- ically structured. Finally, we found a spatial association between fish groups with virulent ISAV (n = 21) and fish groups with ISAV-HPR0 (n = 27), supporting the hypothesis that ISAV-HPR0 may undergo a transition to virulent ISAV.

We describe the finding of a novel viral haemorrhagic septicaemia virus (VHSV) Genotype III strain that caused disease of both a neurological and septicaemic nature in seawater-farmed rainbow trout Oncorhynchus mykiss in Storfjorden, Norway. In November 2007, an outbreak of VHS associated with slightly elevated mortality was confirmed at a seawater site rearing rainbow trout (90 to 440 g). Within 3 to 4 mo, the disease was recognised in 3 neighbouring sea sites with ongrowing rainbow trout. The clinical, gross pathological and histopathological findings were in accordance with VHS, and the diagnosis was confirmed by the detection of VHSV in brain and internal tissues by immunohistochemistry, cell culture and reverse transcriptase PCR (RT-PCR). Sequence analysis of the G-gene revealed that the isolated virus clustered with VHSV Genotype III and that the Norwegian isolate represents a unique strain of VHSV. The pathogenicity of the virus strain to rainbow trout and Atlantic salmon Salmo salar was examined using infection experiments. In immersion trials, the Norwegian isolate produced a cumulative mortality of 70% in rainbow trout, while nearly 100% mortality was obtained after intraperitoneal injection of the virus. For Atlantic salmon, no mortality was observed in immersion trials, whereas 52% mortality was observed after intraperitoneal injection. The Norwegian isolate thus represents the first VHSV of Genotype III pathogenic to rainbow trout.

Since the mid-1980s, clinical inspections of aquaculture sites carried out on a regular basis by authorized veterinarians and fish health biologists (known as fish health services: FHS) have been an essential part of aquatic animal health surveillance in Norway. The aims of the present study were (1) to evaluate the performance of FHS routine clinical inspections for the detection of VHS and (2) to explore the effectiveness of risk-based prioritisation of FHS inspections for demonstrating freedom from VHS in marine salmonid sites in Norway. A stochastic simulation model was developed to estimate site sensitivity (SeS), population sensitivity (SeP), and probability of freedom (PFree). The estimation of SeS takes into consideration the probability that FHS submit samples if a site is infected, the probability that a sample is tested if submitted, the effective probability of infection in fish with clinical signs, laboratory test sensitivity, and the number of tested samples. SeP and PFree were estimated on a monthly basis over a 12 month period for six alternative surveillance scenarios and included the risk factors: region, species, area production density, and biosecurity level. Model results indicate that the current surveillance system, based on routine inspections by the FHS has a high capability for detecting VHS and that there is a high probability of freedom from VHS in Norwegian marine farmed salmonids (PFree >95%). Sensitivity analysis identified the probabilities that samples are submitted and submitted samples are tested, as the most influential input variables. The model provides a supporting tool for evaluation of potential changes in the surveillance strategy, and can be viewed as a platform for similar exotic viral infectious diseases in marine salmonid farming in Norway, if they share similar risk factors.

An expert consultation was conducted to provide quantitative parameters required to inform risk-based surveillance of aquaculture holdings for selected infectious hazards. The hazards were four fish diseases endemic in some or several European countries: infectious salmon anaemia (ISA), viral haemorrhagic septicaemia (VHS), infectious haematopoietic necrosis (IHN), and koi herpes virus disease (KHD). Experts were asked to provide estimates for the relative importance of 5 risk themes for the hazard to be introduced into and infect susceptible fish at the destination. The 5 risk themes were: (1) live fish and egg movements; (2) exposure via water; (3) on-site processing; (4) short distance mechanical transmission and (5) distance independent mechanical transmission. The experts also provided parameter estimates for hazard transmission pathways within the themes. The expert consultation was undertaken in a 2 step approach: an online survey followed by an expert consultation meeting. The expert opinion indicated that live fish movements and exposure via water were the major relevant risk themes. Experts were recruited from several European countries and thus covered a range of farming systems. Therefore, the outputs from the expert consultation have relevance for the European context.

Over recent years there have been considerable methodological developments in the field of animal disease surveillance. The principles of risk analysis were conceptually applied to surveillance in order to further develop approaches and tools (scenario tree modelling) to design risk-based surveillance (RBS) programmes. In the terrestrial animal context, examples of risk-based surveillance have demonstrated the substantial potential for cost saving, and a similar benefit is expected also for aquatic animals. RBS approaches are currently largely absent for aquatic animal diseases. A major constraint in developing RBS designs in the aquatic context is the lack of published data to assist in the design of RBS: this applies to data on (i) the relative risk of farm sites becoming infected due to the presence or absence of a given risk factor; (ii) the sensitivity of diagnostic tests (specificity is often addressed by follow-up investigation and re-testing and therefore less of a concern); (iii) data on the variability of prevalence of infection for fish within a holding unit, between holding units and at farm level. Another constraint is that some of the most basic data for planning surveillance are missing, e.g. data on farm location and animal movements. In Europe, registration or authorisation of fish farms has only recently become a requirement under EU Directive 2006/88. Additionally, the definition of the epidemiological unit (at site or area level) in the context of aquaculture is a challenge due to the often high level of connectedness (mainly via water) of aquaculture facilities with the aquatic environment. This paper provides a review of the principles, methods and examples of RBS in terrestrial, farmed and wild animals. It discusses the special challenges associated with surveillance for aquatic animal diseases (e.g. accessibility of animals for inspection and sampling, complexity of rearing systems) and provides an overview of current developments relevant for the design of RBS for fish diseases. Suggestions are provided on how the current constraints to applying RBS to fish diseases can be overcome.