Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Meticillin-resistant Staphylococcus aureus in Norway, a low-incidence country, 2006-2010

BACKGROUND

Antibiotic resistance is a global public health threat. Norway has managed to keep the incidence of resistant bacteria at a low level in both the healthcare system and the community. Reporting of both individual cases and meticillin-resistant Staphylococcus aureus (MRSA) outbreaks is mandatory. All isolates are genotyped.

AIM

To describe the epidemiology of MRSA in Norway and to analyse how MRSA is spreading in a low-incidence country.

METHODS

All cases of laboratory-confirmed MRSA colonisation and infection reported in Norway from 2006 to 2010 were subject to epidemiological analysis.

FINDINGS

A total of 3620 cases of MRSA were found. Around one-third of the cases were imported, one-third acquired in the Norwegian healthcare system and one-third acquired in the community. Twelve percent of the cases were linked to known outbreaks. The total incidence of infected and colonized patients is slowly increasing. The numbers of severe infections remain stable at around 20 cases annually and the proportion of MRSA cases associated with healthcare has decreased.

CONCLUSION

MRSA is still rare in the Norwegian population and the strategic objective of preventing MRSA from becoming a permanent part of the bacterial flora in hospitals and nursing homes has so far been met.

Differences and commonalities of national field epidemiology training programmes in Europe

From 1994 to 2009, national field epidemiology training programmes (FETP) have been installed in Spain, Germany, Italy, France and Norway. During their two year duration, different components of the FETP are devised as follows: 63-79 weeks are spent on projects in hosting institutes, 2-26 weeks in outside projects, 9-30 weeks in courses and modules, and 1-2 weeks in scientific conferences. A considerable proportion of the Spanish FETP has is provided conventional class room training . The content of the modules is very similar for all programmes. Except from the Italian programme, all focus on infectious disease epidemiology. The German and Norwegian programmes are so called EPIET-associated programmesas their participants are integrated in the modules and the supervision offered by EPIET, but salaries, facilitators, and training sites are provided by the national programme. These EPIET-associated programmes require strong communications skills in English. Alumni of all five FETP are generally working within the public health work force in their respective countries or at international level, many of them in leading functions. Although three new FETP have been installed since the last published Euroroundup in Eurosurveillance on European FETP in 2001, the progress with respect to the establishment of national FETP or EPIET-associated programmes has been slow. Member States should be aware of how much support EPIET can offer for the establishment of national FETP or EPIET-associated programmes. However, they also need to be ready to provide the necessary resources, the administrative environment and long-term dedication to make field epidemiology training work.

Differences and Commonalities of National Field Epidemiology Training Programmes in Europe

From 1994 to 2009, national field epidemiology training programmes (FETP) have been installed in Spain, Germany, Italy, France and Norway. During their two year duration, different components of the FETP are devised as follows: 63-79 weeks are spent on projects in hosting institutes, 2-26 weeks in outside projects, 9-30 weeks in courses and modules, and 1-2 weeks in scientific conferences. A considerable proportion of the Spanish FETP has is provided conventional ‘class room training’. The content of the modules is very similar for all programmes. Except from the Italian programme, all focus on infectious disease epidemiology. The German and Norwegian programmes are so called EPIET-associated programmesas their participants are integrated in the modules and the supervision offered by EPIET, but salaries, facilitators, and training sites are provided by the national programme. These EPIET-associated programmes require strong communications skills in English. Alumni of all five FETP are generally working within the public health work force in their respective countries or at international level, many of them in leading functions. Although three new FETP have been installed since the last published ‘Euroroundup’ in Eurosurveillance on European FETP in 2001, the progress with respect to the establishment of national FETP or EPIET-associated programmes has been slow. Member States should be aware of how much support EPIET can offer for the establishment of national FETP or EPIET-associated programmes. However, they also need to be ready to provide the necessary resources, the administrative environment and long-term dedication to make field epidemiology training work.

Severe consequences of healthcare-associated infections among residents of nursing homes: a cohort study

The aim of this study was to identify the consequences of healthcare-associated infections in Norwegian nursing homes, to include debilitation, hospital transfer and mortality. We followed the residents of six nursing homes in two major cities in Norway during the period October 2004 to March 2005. For each resident with infection we randomly selected two controls among residents who did not have an infection. Cases and the controls were followed for 30 days as a cohort in order to measure the incidence of complications and risk ratio (RR) in the two groups. The incidence of infection was 5.2 per 1000 resident-days. After 30 days follow-up 10.9% of residents who had acquired infection demonstrated a reduction in overall physical condition compared with 4.8% in the unexposed group (RR: 2.3). Altogether 13.0% of residents with infections were admitted to hospital compared with 1.4% in the unexposed group (RR 9.2), and 16.1% residents with infections died in the nursing home during follow-up compared with 2.4% in the unexposed group (RR: 6.6). Residents with lower respiratory tract infections demonstrated higher morbidity and mortality. In conclusion, healthcare-associated infections cause severe consequences for people living in nursing homes, including debilitation, hospital admission and death.

A local outbreak of quinolone-resistant gonorrhoea in Norway, January 2008

Binary file ES_Abstracts_Final_ECDC.txt matches

A local outbreak of quinolone-resistant gonorrhoea in Norway, January 2008

Since 1994, the incidence of gonorrhoea in Østfold county, Norway, has remained within the range of 1-8 cases per year, with 40% of cases being imported from abroad. On 20 January 2008, a general practitioner in the county diagnosed two seemingly unrelated domestic cases of gonorrhoea in three days and started contact tracing. A case was defined as a person with clinical symptoms of gonorrhoea who was a part of the sexual network. Available isolates from the samples taken were tested for resistance. Among 13 contacts identified in the sexual network, eight were classified as cases on the basis of symptoms, four of whom had laboratory-confirmed gonorrhoea. The index case acquired the infection abroad. The three isolated strains were resistant to ciprofloxacin, but sensitive to ceftriaxone which was used for treatment. In the outbreak described, most cases were diagnosed only after contact tracing although they had had symptoms. A quinolone-resistant strain was imported from abroad and introduced into the population. The Norwegian national treatment guidelines, which still recommend quinolones for empirical treatment, should be updated.

An ongoing multi-state outbreak of measles linked to non-immune anthroposophic communities in Austria, Germany, and Norway, March-April 2008

From the second week of March 2008, public health authorities in the province of Salzburg observed an increased number of measles cases compared to previous years. Twenty cases of measles had been were notified Austria-wide in 2007, 24 in 2006, 10 in 2005, and 14 in 2004. The current outbreak has affected, as of 14 April, 202 people in Austria, 53 in Germany, and four in Norway, bringing the total number of cases related to this outbreak to 259. The initial case series investigation revealed that the common link was attendance of an anthroposophic school and day care centre in Salzburg city. The majority of the pupils were not vaccinated against measles.

Outbreak of measles among Irish Travellers in Norway: an update

This is an update on the preliminary report [1] of an outbreak of measles in Norway among a travelling community from England.

An outbreak of measles among a travelling community from England in Norway: a preliminary report

Between 7 and 14 May 2007, Nasjonalt Folkehelseinstitutt (the Norwegian Institute of Public Health, NIPH) was notified of six cases of measles, all occurring in a group of families from England staying at camping sites in Norway.

Healthcare-associated infection among residents of long-term care facilities: a cohort and nested case-control study

Knowledge of infection control measures in nursing homes is limited. This study aimed to assess the incidence of, and potential risk factors for, healthcare-associated infection in long-term care facilities in Norway. Incidence of healthcare-associated infection was recorded prospectively in six long-term care facilities located in two major cities in Norway between 1 October 2004 and 31 March 2005. For each resident with an infection we aimed for two controls in a nested case-control study to identify potential risk factors. Incidence of infection was 5.2 per 1000 resident-days. Urinary and lower respiratory tract infections were the most common. Patients confined to their beds [odds ratio (OR=2.7)], who stayed <28 days (OR=1.5), had chronic heart disease (OR=1.3), urinary incontinence (OR=1.5), an indwelling urinary catheter (OR=2.0) or skin ulcers (OR=1.8) were shown to have a greater risk for infection. Age, sex and accommodated in a two- versus single-bed room were not significant factors. Incidence of infection in nursing homes in Norway is within the range reported from other countries. This study identified several important risk factors for healthcare-associated infection. There is a need to prevent infection by implementing infection control programmes including surveillance in long-term care facilities.

Safety review: two outer membrane vesicle (OMV) vaccines against systemic Neisseria meningitidis serogroup B disease

MenBvac is an OMV vaccine against systemic serogroup B Neisseria meningitidis disease. MenBvac was developed for control of a B:15:P1.7,16 subtype epidemic in Norway and administered to 180,000 subjects in 28 clinical studies. MeNZB, a daughter vaccine of MenBvac, was developed for a clonal B:4:P1.7b,4 epidemic in New Zealand and administered to 1 million people <20 years. The vaccines were similar regarding reactogenicity profile. Serious adverse events (SAEs) in general and particularly neurologic SAEs were very rare. Despite frequently reported local reactions and fever in those under 5 years, these OMV-based vaccines containing 25 microg antigen can be considered safe for use in all age groups.

Outbreak of Salmonella Kedougou in Norway associated with salami, April-June 2006

Nasjonalt folkehelseinstituttet (the Norwegian Institute of Public Health, NIPH) has recently completed the investigation of a nationwide outbreak

An outbreak of haemolytic uraemic syndrome associated with minced beef, Norway, January-February 2006: preliminary report

On 20 and 21 February 2006, six cases of diarrhoea-associated haemolytic uraemic syndrome (HUS) were reported to Nasjonalt

Emerging Salmonella Enteritidis anaerogenic phage type 14b: Outbreak in Norwegian, Swedish and Finnish travellers returning from Greece

In July 2001, the Norwegian Institute of Public Health (Folkehelseinstituttet, FHI) reported a cluster of Salmonella Enteritidis of phage type 14b infections in Norwegian travellers returning from Greece. An increase in the same uncommon phage type was also registered in Sweden and Finland at the same time. Cases of S. Enteritidis PT 14b in patients returning from Greece were reported in these three Nordic countries in 2001 (303 cases), 2002 (164 cases) and 2003 (199 cases). Case-control studies performed in 2001 in Norway and Sweden indicated that consumption of chicken was associated with illness. In 2002 and 2003, continuing case reports indicated that this uncommon phage type had probably become established in the Greek food chain. Tour operators were informed and contacts were made with Greek public health authorities. Because place of infection is not systematically included in most Salmonella notification systems, the S. Enteritidis phage type 14b outbreak reported here may represent only part of a larger outbreak among travellers visiting Greece. Infections are often reported only in the tourists’ home countries and public health authorities in the tourist destinations may not be aware of the problem. Further collaboration between national institutes of public health in Europe is needed to detect outbreaks occurring among tourists.

Emerging Salmonella Enteritidis anaerogenic phage type 14b: outbreak in Norwegian, Swedish and Finnish travellers returning from Greece

In July 2001, the Norwegian Institute of Public Health (Folkehelseinstituttet, FHI) reported a cluster of Salmonella Enteritidis of phage type 14b infections in Norwegian travellers returning from Greece. An increase in the same uncommon phage type was also registered in Sweden and Finland at the same time. Cases of S. Enteritidis PT 14b in patients returning from Greece were reported in these three Nordic countries in 2001 (303 cases), 2002 (164 cases) and 2003 (199 cases). Case-control studies performed in 2001 in Norway and Sweden indicated that consumption of chicken was associated with illness. In 2002 and 2003, continuing case reports indicated that this uncommon phage type had probably become established in the Greek food chain. Tour operators were informed and contacts were made with Greek public health authorities. Because place of infection is not systematically included in most Salmonella notification systems, the S. Enteritidis phage type 14b outbreak reported here may represent only part of a larger outbreak among travellers visiting Greece. Infections are often reported only in the tourists' home countries and public health authorities in the tourist destinations may not be aware of the problem. Further collaboration between national institutes of public health in Europe is needed to detect outbreaks occurring among tourists.

Prevalence of nosocomial infections in hospitals in Norway, 2002 and 2003

The Norwegian Institute of Public Health initiated a national surveillance system for nosocomial infections in 2002. The system is based on two annual one-day prevalence surveys recording the four most common types of nosocomial infection: urinary tract infections; lower respiratory tract infections; surgical site infections and septicaemia. All acute care hospitals in Norway (N=76) were invited to participate in the four surveys in 2002 and 2003. The total prevalence of the four recorded nosocomial infections varied between 5.1% and 5.4% in the four surveys. In all surveys, nosocomial infections were located most frequently in the urinary tract (34%), followed by the lower respiratory tract (29%), surgical sites (28%) and septicaemia (8%). The prevalence surveys give a brief overview of the burden and distribution of nosocomial infections. The results can be used to prioritize further infection control measures and more detailed incidence surveillance of nosocomial infections.

Communicable disease control in a migrant seasonal workers population: A case study in Norway

Reliable data on the health status of migrant seasonal workers in Europe is scarce. Access to public health care for this population depends on national regulations, and their legal status in host countries. In this manuscript we describe a case study of a salmonellosis outbreak that occurred in Norway, and highlight the difficulties encountered in applying control measures in a population of seasonal migrant farm workers. Surveillance and control of infectious diseases need to be supported by legislation which makes implementation of control measures possible. Efforts have been made to improve the rights for migrants in Europe with regard to healthcare, but seasonal migrant workers still remain largely outsiders where these measures are concerned. Special attention should be given to this disadvantaged group in terms of social rights and healthcare. Preparedness plans should be improved to deal with contagious pathogens involving the seasonal migrant population.

Communicable disease control in a migrant seasonal workers population: a case study in Norway

Reliable data on the health status of migrant seasonal workers in Europe is scarce. Access to public health care for this population depends on national regulations, and their legal status in host countries. In this manuscript we describe a case study of a salmonellosis outbreak that occurred in Norway, and highlight the difficulties encountered in applying control measures in a population of seasonal migrant farm workers. Surveillance and control of infectious diseases need to be supported by legislation which makes implementation of control measures possible. Efforts have been made to improve the rights for migrants in Europe with regard to healthcare, but seasonal migrant workers still remain largely outsiders where these measures are concerned. Special attention should be given to this disadvantaged group in terms of social rights and healthcare. Preparedness plans should be improved to deal with contagious pathogens involving the seasonal migrant population.

International outbreak of Salmonella Thompson caused by contaminated ruccola salad - update

We recently reported an outbreak of Salmonella Thompson associated with ruccola salad* in Norway. Almost all of patients interviewed mentioned having eaten ruccola from a pre-prepared salad mix in pre-packed plastic bags.

Case management of a multidrug-resistant Shigella dysenteriae serotype 1 outbreak in a crisis context in Sierra Leone, 1999-2000

From December 1999 to the end of February 2000, 4218 cases of dysentery were reported in Kenema district, southeastern Sierra Leone, by a Médecins Sans Frontières team operating in this region. Shigella dysenteriae serotype 1 was isolated from the early cases. The overall attack rate was 7.5% but higher among children under 5 years (11.2%) compared to the rest of the population (6.8%) (RR = 1.6; 95% CI 1.5-1.8). The case fatality ratio was 3.1%, and higher for children under 5 years (6.1% vs. 2.1%) (RR = 2.9; 95% CI 2.1-4.1). A case management strategy based on stratification of affected cases was chosen in this resource-poor setting. Patients considered at higher risk of death were treated with a 5 day ciprofloxacin regimen in isolation centres. Five hundred and eighty-three cases were treated with a case fatality ratio of 0.9%. Patients who did not have signs of severity when seen by health workers were given hygiene advice and oral rehydration salts. This strategy was effective in this complex emergency.

Outbreak of Salmonella Livingstone infection in Norway and Sweden due to contaminated processed fish products

In Europe, the number of reported sporadic human cases of Salmonella Livingstone infection is low, and outbreaks are rare. We report the largest S. Livingstone outbreak described in the literature having an identified source of infection. In February 2001, an increased incidence of infection caused by S. Livingstone was observed in Norway and Sweden. By July 2001, 44 cases were notified in Norway and 16 in Sweden. The median age was 63 years, and 40 were women. There were three deaths, and 22 patients were hospitalized. Based on standardized questionnaires and retrospective studies of S. Livingstone strains in Norway and Sweden, food items with egg powder were suspected, and S. Livingstone was subsequently recovered from a processed fish product at the retail level. Analysis by pulsed-field gel electrophoresis documented that isolates from the fish product belonged to the same clone as the outbreak strain.

Prevalence of nosocomial infections and use of antibiotics in long-term care facilities in Norway, 2002 and 2003

There were 42900 institution-beds in long-term care facilities for elderly persons in Norway in 2000. This is twice as many as in 1984. Of those living in an elderly people's care institution 77% were above 80 years. To determine the magnitude and distribution of nosocomial infections in such institutions, the Norwegian Institute of Public Health initiated a surveillance system. The system is based on two annual one-day prevalence surveys recording the four most common nosocomial infections: urinary tract infections, lower respiratory tract infections, surgical-site infections and skin infections, as well as antibiotic use. All long-term care facilities were invited to participate in the four surveys in 2002 and 2003. The total prevalence of the four recorded nosocomial infections varied between 6.6 and 7.3% in the four surveys. Nosocomial infections occurred most frequently in the urinary tract (50%), followed by infections of the skin (25%), of the lower respiratory tract (19%) and of surgical sites (5%). The prevalence of nosocomial infections was highest in rehabilitation and short-term wards, whereas the lowest prevalence was found in special units for persons with dementia. In all the surveys the prevalence of the four recorded nosocomial infections was higher than the prevalence of patients receiving antibiotics. The frequency of nosocomial infections in such facilities highlights the need for nosocomial infection surveillance in this population and a need to implement infection control measures, such as infection control programmes including surveillance of nosocomial infections.

Waterborne outbreak of gastroenteritis in a religious summer camp in Norway, 2002

In July 2002 an outbreak of acute gastroenteritis occurred in a camp facility in western Norway during a 10-day seminar, with around 300 guests staying overnight and several day-time visitors. Environmental and epidemiological investigations were conducted to identify and eliminate the source of the outbreak, prevent further transmission and describe the impact of the outbreak. Of 205 respondents, 134 reported illness (attack rate, 65%). Multivariate analysis showed drinking water and taking showers at the camp-site to be significant risk factors. Secondary person-to-person spread among visitors or outside of the camp was found. Norovirus was identified in 8 out of the 10 stool samples analysed. Indicators of faecal contamination were found in samples from the private untreated water supply, but norovirus could not be identified. This outbreak investigation illustrates the importance of norovirus as a cause of waterborne illness and the additional exacerbation through person-to-person transmission in closed settings. Since aerosol transmission through showering contributed to the spread, intensified hygienic procedures such as isolation of cases and boiling of water may not be sufficient to terminate outbreaks with norovirus.

Incidence of gastroenteritis in Norway--a population-based survey

In 1999-2000 we conducted a one-year, retrospective population-based survey in Norway to estimate the incidence of gastroenteritis and study the association with selected exposures. A self-administered questionnaire was mailed to 3000 persons selected at random from the population registry, with 250 persons being contacted each month. The response rate was 61%. The incidence of acute gastroenteritis was 1.2 per person-year. The incidence was higher for women than for men. Of the total of 171 cases, 29 (17%) consulted a physician, 13 (8%) reported that a stool sample was taken, and 7 (4%) were admitted to hospital. Among children aged less than 15 years, drinking water from a private water supply was associated with illness, while using chlorinated water was protective. Among adults aged 20-40 years, travelling abroad was associated with illness. The incidence in our survey is similar to rates found by FoodNet in United States.

Syphilis outbreak in Norway and Sweden among men who have sex with men 1998-2002

The incidence of infectious syphilis in both Norway (4.5 million inhabitants) and Sweden (8.8 million) fell to an all time low in the mid 1990s.

Impact of antenatal HIV screening to prevent HIV infection in children in Norway 1987-99

OBJECTIVE

To assess the impact of the antenatal HIV screening programme in Norway in preventing HIV infection in children.

SETTING

Norway, 1987-99.

METHODS

In a simulated retrospective cohort design data were used from the mandatory HIV surveillance system to compare the observed number of children born infected with HIV in Norway 1987-99 to the expected number without the antenatal screening programme. The main measures were relative and absolute performance of the screening programme. Other measures were uptake and false positive rate of screening, and number and exposure category of screen positive women.

RESULTS

96% of 961 000 eligible pregnant women were tested. 0.1% had an indeterminate test result and 46 women (5.0/100 000) were confirmed screen positive. 27 were African or south east Asian women infected before immigration to Norway. Nine out of 739 000 live born children (1.2/100 000) were infected compared with the expected 18 with no screening. The absolute impact of the screening programme was 1.3 (95% confidence interval (95% CI) -0.1 to 2.7) prevented infections in 100 000 women screened. The relative preventive impact was 51% (-15% to 81%).

CONCLUSIONS

The limited absolute impact is because of the very low prevalence of undetected HIV infection among pregnant women in Norway.

Anonymous reporting of HIV infection: an evaluation of the HIV/AIDS surveillance system in Norway 1983-2000

Several European countries are considering implementing surveillance systems for HIV infection, but questions remain regarding patient confidentiality. The population-based HIV/AIDS surveillance system in Norway integrates anonymous HIV case reports from laboratories and clinicians and named AIDS case reports. This evaluation includes a description of the system, evidence of system attributes, estimation of resources for system operations, and documentation of the system's usefulness. HIV case reports provide a far better picture of the epidemic than AIDS reports. The median delay between positive HIV test and reporting was 30 days (interquartile range 18-49 days). Completeness of demographic and epidemiologic information in the surveillance database ranges from 60 to 100%. Information on pre-AIDS mortality and emigration is incomplete. The system cost euro 25,200 in 1999. Results are published every week and used for planning of health care and prevention. We conclude that the Norwegian surveillance system with anonymous reporting of HIV cases is simple, inexpensive and flexible, and capable of providing a representative and timely overview that guides prevention. The system fulfils its objectives while respecting confidentiality and adhering to ethical principles. A similar system may be considered in other countries.

Communicable disease epidemiology training in Northern Europe

The five Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) have a long tradition of collaboration in communicable disease epidemiology and control. The state epidemiologists and the immunisation programme managers have met regularly to discuss common challenges and exchange experiences in surveillance and control of communicable diseases. After the three Baltic countries (Estonia, Latvia and Lithuania) regained independence in 1991 and the Soviet Union dissolved, contacts were made across the old iron curtain in several areas, such as culture, education, business, military and medicine. Each of the Nordic communicable disease surveillance institutes started projects with partners in Estonia, Latvia, Lithuania or the Russian Federation. The projects were in such diverse areas as HIV surveillance and prevention, vaccination programmes and antibiotic resistance.

[HIV infection from Africa to Norway]

BACKGROUND

More than two thirds of the world's HIV infected persons live in Africa. Africans seek asylum in Norway and some Norwegians work for longer periods in Africa. We used the Norwegian surveillance system for communicable diseases (1983-99) to assess the connections between the Norwegian and African epidemics.

MATERIAL AND METHODS

We estimated the incidence of HIV infection in persons from Norway who acquired HIV from Africans, and measured the annual number of Africans diagnosed in Norway.

RESULTS

Out of the 2,016 cases of HIV infection ever diagnosed in Norway (population 4.4 million), 489 (24%) had connections to Africa. 80 persons from Norway have been infected in Africa, usually during work for aid agencies. 39 persons have been infected by Africans in Norway. For both groups the annual number of new cases was 0-2 in 1997-99. Cumulatively, 370 Africans have been diagnosed with HIV infection acquired before immigration. Median time from immigration to diagnosis is three months.

INTERPRETATION

Currently, few Norwegians are infected by Africans in Norway or Africa. African immigrants constitute an increasing proportion of the HIV positive population in Norway. This is a challenge to the health services and to society at large.

[Attitude of pregnant women to routine voluntary antenatal HIV testing]

INTRODUCTION

Since 1987, more than 95% of pregnant Norwegian women have accepted the offer of an antenatal HIV test. We investigated women's opinion regarding antenatal HIV testing.

MATERIAL AND METHODS

In an anonymous questionnaire survey in 1997, we asked 500 randomly selected women who had recently given birth about their knowledge about HIV, perception of the information given, and their attitudes towards HIV testing.

RESULTS

The response rate was 74%. Half the women knew that testing was voluntary. 30% were satisfied with the information. This was associated with having been told that the test was voluntary (odds ratio 13). 61% of those who were tested, were told so. 75% of the women would opt for HIV testing in a future pregnancy and most women wanted the offer of a test to be routine procedure.

INTERPRETATION

Women do not receive information that meets their needs. The programme does not accord with its objectives and is hardly ethically justifiable. There is a need for more information, especially concerning the voluntary character of antenatal HIV testing.

[Meningococcal disease in Africa--epidemiology and prevention]

Neisseria meningitidis is one of the most common causes of purulent meningitis all over the world. Large epidemics caused by meningococci have spread during the last decade throughout vast areas of Africa, also outside the region referred to as the classic "Meningitis Belt". Globally, this organism each year causes about 300,000 cases and 30,000 deaths; most of these are children. Meningococci of serogroup A cause a major part of these epidemics, and a remarkable feature of the epidemical situation is that the bacteria differ very little in antigenic properties as they belong to the same clonal group of meningococci. Immunization with safe and effective vaccines is the most efficient way of combatting these epidemics. The currently available polysaccharide vaccines against serogroup. A meningococcal disease do not induce long-term immunological memory and do not provide adequate protection of children below two years of age. There is an urgent need for a vaccine that induces long-term immunological memory in all age groups, so it can be included in the routine vaccination program. In contrast to serogroup C, the development of conjugate vaccines against serogroup A meningococcal disease has not yielded the positive results hoped for. The development of alternative protein-based vaccines therefore needs to be intensified.

[HIV infection, gonorrhea and syphilis from Thailand to Norway]

Thailand, a popular tourist destination for Norwegians, is experiencing an increasing epidemic of HIV infection. We used the Norwegian surveillance system for communicable diseases to assess the connections between the Norwegian and Thai epidemics. Before 1999, 1,869 cases of HIV-infection had been reported in Norway. From 1993 to 1998, 1,334 cases of gonorrhoea and 62 cases of syphilis were reported. We studied cases with a Thai patient or source partner and cases acquired in Thailand. 56 (3%) of HIV-infection cases, 64 (5%) of gonorrhoea cases and two (3%) of syphilis cases were connected to Thailand. All the Norwegians who acquired HIV in Thailand were males, with a median age of 39. Eight of them were diagnosed in 1998 as compared to 16 during the previous ten-year period. 21 Thai women and seven males were diagnosed with HIV infection in Norway, eight in 1998 and 20 in the previous ten-year period. The Norwegian HIV epidemic is influenced by the Thai epidemic. Norwegian men are infected in Thailand during holidays. Thai women come with their Norwegian partner to Norway and later discover their HIV status. We recommend raising the awareness of the Thai epidemic among Norwegian tourists. Immigrants to Norway from highly endemic countries should be offered HIV counselling and testing.