Norwegian Institute Of Public Health Research Articles

Occurrence of N-nitrosamines in the atmosphere and human health risk: A case study in an urban area of Chuncheon, Gangwon State, South Korea

This study aimed to investigate the occurrence of eight nitrosamines (NAs) in particulate (PM2.5) and gaseous phases and assess the human health risk associated with these compounds in an urban area of Chuncheon, Gangwon State, South Korea, across four sampling seasons. The findings revealed that the total concentrations of eight NAs measured during the sampling period exceeded the public health recommendation of 0.3 ng/m3 provided by the Norwegian Institute of Public Health, indicating a potential human health risk from NA exposures. In particular, the average total NA concentration observed in the gaseous samples during the winter of 2021 was 18.1 ± 6.46 ng/m3. The primary emission sources could potentially impact the concentrations of NAs in the atmosphere due to their significant positive correlation with primary emission species such as NO2, CO, and SO2. Moreover, the levels of particulate NAs during the summer were negatively correlated with O3, suggesting that their formation might be influenced by ozonation in the aqueous aerosol phase. In addition, the total NA concentrations measured in the gaseous phase were four to six times higher than those measured in the PM2.5 phase throughout the sampling period. Thus, domestic sources have the potential to impact the pollution levels of the research area more significantly than long-range atmospheric transport. In particular, the highest concentrations of NAs in the gas phase were observed during the winter, while the lowest concentrations were recorded in the summer, possibly influenced by photolysis. Nevertheless, the study suggested that tertiary amines might contribute to the presence of gaseous NAs in sunlight. Consequently, further studies focusing on the occurrence of tertiary amines in the gas phase should be considered. The cumulative lifetime cancer risks estimated from inhalation exposure exceeded the acceptable risk level of 10⁻6 for all age groups across all four seasons. Therefore, it is crucial to implement effective control measures to mitigate potential health risks associated with exposure to NAs.

Early or late menarche is associated with reduced fecundability in the Norwegian Mother, Father and Child Cohort Study.

Is age at menarche associated with fecundability? Both early (<11 years) and late (>15 years) menarche is associated with decreased fecundability. Previous studies on age at menarche and fecundability have been inconclusive. Women with early or late menarche are at increased risks of gynaecological and autoimmune diseases that may affect their ability to conceive. We conducted a retrospective cohort study including 67 613 pregnant women, participating in the Norwegian Mother, Father and Child Cohort Study between 1999 and 2008, with self-reported information on age at menarche and time to pregnancy. We included planned pregnancies that were conceived either naturally or with the help of assisted reproductive technologies. We calculated fecundability ratios (FRs) with 95% CIs representing the cycle-specific probability of conception by categories of age at menarche. FRs were adjusted for participants' pre-pregnancy body mass index, highest completed or ongoing education level, and age at initiation of trying to conceive. We observed a 7% lower probability of conceiving during any given menstrual cycle up to 12 cycles in women with early or late menarche. Among women with menarche >15 years, the adjusted FR was 0.93 (95% CI: 0.90-0.97), and among women with menarche <11 years, the adjusted FR was 0.93 (95% CI: 0.89-0.99), when compared to women with menarche between 12 and 14 years. The study-population consisted of women pregnant in their second trimester, excluding those with persistent infertility. Recall of age at menarche and time to pregnancy may be inaccurate. Both early (<11 years) and late (>15 years) menarche was associated with decreased fecundability. Women experiencing early menarche or late menarche may be counselled accordingly. This study was funded by the Norwegian Institute of Public Health, Oslo, Norway, and by Telemark Hospital Trust, Porsgrunn, Norway and was partly supported by the Research Council of Norway through its centres of excellence funding scheme (project number 262700) and the Research Council of Norway (project no. 320656). The project was co-funded by the European Union (ERC, BIOSFER, 101071773). Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or the European Research Council. Neither the European Union nor the granting authority can be held responsible for them. M.C.M. has received funding from the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation program (grant agreement no. 947684). The authors report no competing interests. N/A.

Building and maintaining trust through the early phase of the COVID-19 pandemic: A content analysis of communiques delivered by the Norwegian Minister of health and care services

The COVID-19 pandemic presented not only a challenge to leaders' decision-making, but also to their ability to demonstrate effective crisis and emergency communication. This study examines the communication delivered by the Norwegian Minister of Health and Care services during the first six months of the COVID-19 pandemic, corresponding to the first wave of infection timeframe. Communiques were analysed through a process of coding to identify 15 Crisis and Emergency Risk Communication (CERC) themes, in addition to word cloud analyses and KWIC-analyses. The results were aligned with policy stringency, public health measures from the Norwegian Institute of Public Health (NIPH) and trust data from the Norwegian Directorate of Health (NDH) over timeframe to examine changes in communication. The study revealed that the communication delivered by the Minister included many of the CERC features, although communication failures could be observed, coinciding with reduction in the public's trust in the health authorities. Despite reduced trust, however, compliance with the precautionary measures against COVID-19 was still high. A likely explanation might be that the inherent trust in the health authorities was high, and that the simple, repeated efficacy messages was understood by the public—‘wash your hands and keep a distance’. These findings indicate that keeping communication science-based, transparent, accurate, and consistent, and never compromise with honesty and truthfulness, are keys in crisis and emergency situations. Being a leader in an organization with high inherent trust may also help.

Conducting a health technology assessment in the West Bank, occupied Palestinian territory: lessons from a feasibility project.

To achieve universal health coverage (UHC), countries must make difficult choices to optimize the use of scarce resources. There is a growing interest in using evidence-based priority setting processes, such as Health Technology Assessment (HTA), to inform these decisions. In 2020, the Palestinian Institute of Public Health (PNIPH) and the Norwegian Institute of Public Health (NIPH) initiated a pilot to test the feasibility of coproducing an HTA on breast cancer screening in the West Bank, occupied Palestinian Territory. Additionally, a secondary aim was to test whether using an adaptive HTA (aHTA) approach that searched and transferred published evidence syntheses could increase the speed of HTA production. The applied stepwise approach to the HTA is described in detail and can be summarized as defining a core team, topic selection, and prioritization; undertaking the HTA including adaptation using tools from the European Network for HTA (EUnetHTA) and stakeholder engagement; and concluding with dissemination. The aHTA approach was faster but not as quick as anticipated, which is attributed to (i) the lack of availability of local evidence for contextualizing findings and (ii) the necessity to build trust between the team and stakeholders. Some delays followed from the COVID-19 pandemic, which showed the importance of good risk anticipation and mitigation. Lastly, other important lessons included the ability of virtual collaborations, the value of capacity strengthening initiatives within low- and middle-income countries (LMICs), and the need for early stakeholder engagement. Overall, the pilot was successfully completed. This was the first HTA of its kind produced in Palestine, and despite the challenges, it shows that HTA analysis is feasible in this setting.

Impaired glucose tolerance and cardiovascular risk factors in relation to infertility: a Mendelian randomization analysis in the Norwegian Mother, Father, and Child Cohort Study.

Are impaired glucose tolerance (as measured by fasting glucose, glycated hemoglobin, and fasting insulin) and cardiovascular disease risk (as measured by low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, systolic blood pressure, and diastolic blood pressure) causally related to infertility? Genetic instruments suggest that higher fasting insulin may increase infertility in women. Observational evidence suggests a shared etiology between impaired glucose tolerance, cardiovascular risk, and fertility problems. This study included two-sample Mendelian randomization (MR) analyses, in which we used genome-wide association summary data that were publicly available for the biomarkers of impaired glucose tolerance and cardiovascular disease, and sex-specific genome-wide association studies (GWASs) of infertility conducted in the Norwegian Mother, Father, and Child Cohort Study. There were 68 882 women (average age 30, involved in 81 682 pregnancies) and 47 474 of their male partners (average age 33, 55 744 pregnancies) who had available genotype data and who provided self-reported information on time-to-pregnancy and use of ARTs. Of couples, 12% were infertile (having tried to conceive for ≥12 months or used ARTs to conceive). We applied the inverse variance weighted method with random effects to pool data across variants and a series of sensitivity analyses to explore genetic instrument validity. (We checked the robustness of genetic instruments and the lack of unbalanced horizontal pleiotropy, and we used methods that are robust to population stratification.) Findings were corrected for multiple comparisons by the Bonferroni method (eight exposures: P-value < 0.00625). In women, increases in genetically determined fasting insulin levels were associated with greater odds of infertility (+1 log(pmol/l): odds ratio 1.60, 95% CI 1.17 to 2.18, P-value = 0.003). The results were robust in the sensitivity analyses exploring the validity of MR assumptions and the role of pleiotropy of other cardiometabolic risk factors. There was also evidence of higher glucose and glycated hemoglobin causing infertility in women, but the findings were imprecise and did not pass our P-value threshold for multiple testing. The results for lipids and blood pressure were close to the null, suggesting that these did not cause infertility. We did not know if underlying causes of infertility were in the woman, man, or both. Our analyses only involved couples who had conceived. We did not have data on circulating levels of cardiometabolic risk factors, and we opted to conduct an MR analysis using GWAS summary statistics. No sex-specific genetic instruments on cardiometabolic risk factors were available. Our results may be affected by selection and misclassification bias. Finally, the characteristics of our study sample limit the generalizability of our results to populations of non-European ancestry. Treatments for lower fasting insulin levels may reduce the risk of infertility in women. The MoBa Cohort Study is supported by the Norwegian Ministry of Health and Care Services and the Norwegian Ministry of Education and Research. This work was supported by the European Research Council [grant numbers 947684, 101071773, 293574, 101021566], the Research Council of Norway [grant numbers 262700, 320656, 274611], the South-Eastern Norway Regional Health Authority [grant numbers 2020022, 2021045], and the British Heart Foundation [grant numbers CH/F/20/90003, AA/18/1/34219]. Open Access funding was provided by the Norwegian Institute of Public Health. The funders had no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the article for publication. D.A.L. has received research support from National and International government and charitable bodies, Roche Diagnostics and Medtronic for research unrelated to the current work. O.A.A. has been a consultant to HealthLytix. The rest of the authors declare that no competing interests exist. N/A.

On the problem of communication in a diverse society

Abstract At present, beyond occasional guidelines for international meetings such as those of the GSMERH (Global Society for Migration Ethnicity Race &amp; Health) and debates between academics, there is very little international debate about the issue of terminology and diversity. This may stem from the apparent hegemony of English and a lack of capacity to debate terms across or between languages. In general, there is a tendency to shy away from discussing how language can be discriminatory, distressing or damaging. There is more commonly, at least in political life, a discussion about “woke” or “politically correct” language, as if this represented an unacceptable brake on the use of terms that the proponents of such arguments would espouse. Alternatively, it is argued that these are the “scientific or appropriate technical terms” as if there were no room for debate or development in the use of language. And yet lists or directories such as the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the United States MESH terms are recognised as essential tools in communication between professionals. And the Disability movements have certainly been active in arguing for non-stigmatising use of terms such as “blind” and “deaf”, “handicapped”, and the like, while there is a lively debate around the labelling and categorisation of gender, sexual orientation, race and ethnicity. These, however, have barely touched the consciousness, we argue, of the health scientific community and public health. This workshop with Bernadette Kumar, Norwegian Institute of Public Health, Mark Johnson, De Montfort University Leicester and Raj Bhopal, University of Edinburgh seeks to raise the level of debate and start the process of movement towards a more informed and useful conversation that will facilitate and improve communication and respect between the “describers” and the “described”, as well as in scientific usage.

Case report Norway

Abstract Norway gathers health information about the population through the 18 central law-regulated health registries and a system of questionnaire-based health surveys. The health registries, including the Medical Birth Registry (founded in 1967) and the Cause of Death Registry (founded in 1951) contain information about the entire population, with data linked to the unique personal identification number, which makes them valuable and trustworthy data sources. In general, surveys can be less dependable, in that participation rates are falling, and participants may not be representative. International data reporting has been regarded as important for Norway, which has reported data to WHO's Health for All database back to 1970. When the SDG indicators were requested by the UN and WHO, Norway was able to deliver 26 of the 28 indicators (93%) on the UN list, though some indicators, such as 3.3.3 (Malaria incidence), were regarded as unnecessary. Indicators 3.5.1 (Substance use treatment interventions) and 3.b.3 (Health facilities with essential medicines) are not reported because of the organisation of the health system. From 2015, the Norwegian Ministry of Health and other national agencies have discussed the validity of the SDG targets for Norway. In 2017, Statistics Norway published a report about the availability of SDG indicators for Norway, and in 2018 a meeting between the relevant ministries resulted in a decision to start reporting the official UN indicators. In 2021 Statistics Norway published a taxonomy of the SDG indicators, and the same year, published all available indicators in a bilingual SDG portal on their web pages. The same year, the Norwegian Ministry of Health decided to start adding to the official UN SDG 3 indicators, and in collaboration between the Norwegian Institute of Public Health and Statistics Norway, 16 extra indicators describing the SDG 3 targets have been defined and are being published, with another 20 in the pipeline.

Unexpected vaginal bleeding and COVID-19 vaccination in nonmenstruating women.

The association between coronavirus disease 2019 (COVID-19) vaccination and vaginal bleeding among nonmenstruating women is not well studied. The Norwegian Institute of Public Health followed several cohorts throughout the pandemic and early performed a systematic data collection of self-reported unexpected vaginal bleeding in nonmenstruating women. Among 7725 postmenopausal women, 7148 perimenopausal women, and 7052 premenopausal women, 3.3, 14.1, and 13.1% experienced unexpected vaginal bleeding during a period of 8 to 9 months, respectively. In postmenopausal women, the risk of unexpected vaginal bleeding (i.e., postmenopausal bleeding) in the 4 weeks after COVID-19 vaccination was increased two- to threefold, compared to a prevaccination period. The corresponding risk of unexpected vaginal bleeding after vaccination was increased three- to fivefold in both nonmenstruating peri- and premenopausal women. In the premenopausal women, Spikevax was associated with at 32% increased risk as compared to Comirnaty. Our results must be confirmed in future studies.

Antibiotic prescriptions among dentists across Norway and the impact of COVID-19 pandemic

BackgroundThe prescription of antibiotics in dental practice contributes significantly to the total use of antibiotics in primary healthcare. This study aimed to evaluate antibiotic prescription in dental practice during the years 2016–2021 in Norway and their relative contribution to national outpatient consumption and to investigate the influence of age, gender, geographic region, and COVID-19. A further aim was to review differences in prescribing patterns to verify effect of governmental strategies to reduce over-prescribing of antibiotics.MethodsThis register study investigated the national antibiotic prescription between 2016 and 2021. Data was obtained from the Norwegian prescription register, the Norwegian Institute of Public Health and Statistics Norway. The consumption of 12 common antibiotics was measured using WHO defined daily doses (DDDs), DDD per 1000 inhabitants per day (DIDs 1000).ResultsA total of 6,049,445 antibiotic prescriptions of the 12 investigated compounds were issued in primary care during the study period. Dentists accounted for 942,350 prescriptions corresponding to 15.6% of the total. An overall decrease in the number of prescriptions by health professions other than dentists during the 5 years (IRR = 0.92, 95% CI:0.92–0.93, p < 0.001) was observed. For dentists a slight increase in the number of prescriptions (IRR = 1.01, 95% CI: 1.01–1.01, p < 0.001) was seen over the study period. The increase of antibiotic prescriptions in dentistry was more pronounced during the COVID-19 pandemic. The 4 most prescribed type of antibiotics based on average number of DDDs of the total period 2016–2021 were in descending order; phenoxymethylpenicillin (1,109,150) followed by amoxicillin (126,244), clindamycin (72,565), and metronidazole (64,599). An unexpected finding was that the prescription of the combination compound amoxicillin/clavulanic acid had significantly increased in dentistry during the last 5 years. Geographic, gender, and age differences in the rates of prescriptions were also seen. The data revealed that there are seasonal variations in dental prescriptions.ConclusionsNoticeable differences exist in prescribing patterns of antibiotics in the last 5 years. Restricted access to dental care due to COVID-19 may have resulted in increased antibiotic prescribing in dentistry as opposed to an otherwise downward trend. Despite national guidelines there is still a need for improvement of antibiotic stewardship in dentistry and to define effective methods to disseminate information.

Evaluation of the pilot wastewater surveillance for SARS-CoV-2 in Norway, June 2022 – March 2023

BackgroundDuring the COVID-19 pandemic, wastewater-based surveillance gained great international interest as an additional tool to monitor SARS-CoV-2. In autumn 2021, the Norwegian Institute of Public Health decided to pilot a national wastewater surveillance (WWS) system for SARS-CoV-2 and its variants between June 2022 and March 2023. We evaluated the system to assess if it met its objectives and its attribute-based performance.MethodsWe adapted the available guidelines for evaluation of surveillance systems. The evaluation was carried out as a descriptive analysis and consisted of the following three steps: (i) description of the WWS system, (ii) identification of users and stakeholders, and (iii) analysis of the system’s attributes and performance including sensitivity, specificity, timeliness, usefulness, representativeness, simplicity, flexibility, stability, and communication. Cross-correlation analysis was performed to assess the system’s ability to provide early warning signal of new wave of infections.ResultsThe pilot WWS system was a national surveillance system using existing wastewater infrastructures from the largest Norwegian municipalities. We found that the system was sensitive, timely, useful, representative, simple, flexible, acceptable, and stable to follow the general trend of infection. Preliminary results indicate that the system could provide an early signal of changes in variant distribution. However, challenges may arise with: (i) specificity due to temporary fluctuations of RNA levels in wastewater, (ii) representativeness when downscaling, and (iii) flexibility and acceptability when upscaling the system due to limited resources and/or capacity.ConclusionsOur results showed that the pilot WWS system met most of its surveillance objectives. The system was able to provide an early warning signal of 1-2 weeks, and the system was useful to monitor infections at population level and complement routine surveillance when individual testing activity was low. However, temporary fluctuations of WWS values need to be carefully interpreted. To improve quality and efficiency, we recommend to standardise and validate methods for assessing trends of new waves of infection and variants, evaluate the WWS system using a longer operational period particularly for new variants, and conduct prevalence studies in the population to calibrate the system and improve data interpretation.

How the Norwegian Institute of Public Health calculated excess mortality

How the Norwegian Institute of Public Health calculated excess mortality

Determinants of humoral and cellular immune responses to three doses of mRNA SARS-CoV-2 vaccines in older adults: a longitudinal cohort study

Older age is associated with poorer outcomes to COVID-19 infection. The Norwegian Institute of Public Health established a longitudinal cohort of adults aged 65-80 years to study the effects of the COVID-19 pandemic. Here we describe the characteristics of the cohort in general, and specifically the immune responses at baseline and after primary and booster vaccination in a subset of longitudinal blood samples, and the epidemiological factors affecting these responses. 4551 participants were recruited, with humoral (n=299) and cellular (n=90) responses measured before vaccination and after two and three vaccine doses. Information on general health, infections, and vaccinations were obtained from questionnaires and national health registries. Half of the participants had a chronic condition. 849 (18·7%) of 4551 were prefrail and 184 (4%) of 4551 were frail. 483 (10·6%) of 4551 had general activity limitations (scored with the Global Activity Limitation Index). After dose two, 295 (98·7%) of 299 participants were seropositive for anti-receptor binding domain IgG, and 210 (100%) of 210 participants after dose three. Spike-specific CD4 and CD8 T cell responses showed high heterogeneity after vaccination and responded to the alpha (B.1.1.7), delta (B.1.617.2), and omicron (B.1.1.529 or BA.1) variants of concern. Cellular responses to seasonal coronaviruses increased after SARS-CoV-2 vaccination. Heterologous prime boosting with mRNA vaccines was associated with the highest antibody (p=0·019) and CD4 T cell responses (p=0·003), and hypertension with lower antibody levels after three doses (p=0·04). Most older adults, including those with comorbidities, generated good serological and cellular responses after two vaccine doses. Responses further improved after three doses, particularly after heterologous boosting. Vaccination also generated cross-reactive T cells against variants of concern and seasonal coronaviruses. Frailty was not associated with impaired immune responses, but hypertension might indicate reduced responsiveness to vaccines even after three doses. Individual differences identified through longitudinal sampling enables better prediction of the variability of vaccine responses, which can help guide future policy on the need for subsequent doses and their timing. Norwegian Institute of Public Health, Norwegian Ministry of Health, Research Council of Norway, and Coalition for Epidemic Preparedness Innovations.

Optimizing the literature search: coverage of included references in systematic reviews in Medline and Embase.

The aim of this study was to investigate if the included references in a set of completed systematic reviews are indexed in Ovid MEDLINE and Ovid Embase, and how many references would be missed if we were to constrict our literature searches to one of these sources, or the two databases in combination. We conducted a cross-sectional study where we searched for each included reference (n = 4,709) in 274 reviews produced by the Norwegian Institute of Public Health to find out if the references were indexed in the respective databases. The data was recorded in an Excel spreadsheet where we calculated the indexing rate. The reviews were sorted into eight categories to see if the indexing rate differs from subject to subject. The indexing rate in MEDLINE (86.6%) was slightly lower than in Embase (88.2%). Without the MEDLINE records in Embase, the indexing rate in Embase was 71.8%. The highest indexing rate was achieved by combining both databases (90.2%). The indexing rate was highest in the category "Physical health - treatment" (97.4%). The category "Welfare" had the lowest indexing rate (58.9%). Our data reveals that 9.8% of the references are not indexed in either database. Furthermore, in 5% of the reviews, the indexing rate was 50% or lower.

Clusters of healthcare-associated SARS-CoV-2 infections in Norwegian hospitals detected by a fully automatic register-based surveillance system

Notifications to the Norwegian Institute of Public Health of outbreaks in Norwegian healthcare institutions are mandatory by law, but under-reporting is suspected due to failure to identify clusters, or because of human or system-based factors. This study aimed to establish and describe a fully automatic, register-based surveillance system to identify clusters of healthcare-associated infections (HAIs) of SARS-CoV-2 in hospitals and compare these with outbreaks notified through the mandated outbreak system Vesuv. We used linked data from the emergency preparedness register Beredt C19, based on the Norwegian Patient Registry and the Norwegian Surveillance System for Communicable Diseases. We tested two different algorithms for HAI clusters, described their size and compared them with outbreaks notified through Vesuv. A total of 5033 patients were registered with an indeterminate, probable, or definite HAI. Depending on the algorithm, our system detected 44 or 36 of the 56 officially notified outbreaks. Both algorithms detected more clusters then officially reported (301 and 206, respectively). It was possible to use existing data sources to establish a fully automatic surveillance system identifying clusters of SARS-CoV-2. Automatic surveillance can improve preparedness through earlier identification of clusters of HAIs, and by lowering the workloads of infection control specialists in hospitals.

Antibody tests for identification of current and past infection with SARS-CoV-2.

Antibody tests for identification of current and past infection with SARS-CoV-2.

The NIPH’s response to the climate and environmental crisis

Abstract The vision of the Norwegian Institute of Public Health (NIPH) is better health for all. Climate changes and health are among our main strategic priorities. The NIPH aims to become a key actor in questions relating to climate, environment, food and health. An action plan on climate changes and environmental health is under development and will be presented. Climate and environmental changes affect the mental and physical health in several ways. The NIPH will in the coming years develop new knowledge on health consequences of climate changes: causes, risks, health effects and measures, based on our methodological expertise, research activities and infrastructures, such as health registers, health examinations, laboratories and biobanks. A key issue, and a main priority of the NIPH, is sustainable and climate-adapted food systems. There is a strong need to strengthen knowledge on healthy, safe and globally sustainable food. We will present and discuss our action plan for addressing climate and environmental health: Priorities, experiences, and challenges in implementation regarding e.g. competence and capacity building. The following examples will be given: – Research that addresses the food problem, and how to ensure a sustainable diet. – The development of the MoBa Human Environmental Biobank to understand how climate and environmental changes affect exposure and public health, and how to follow the changes over time and help prevent disease. – Examples of activities relating to clean air, clean and safe drinking water, and safe products from a One Health perspective: Achievements, projects, networks. – Challenges in communicating health risks associated with the climate, environmental and pollution crisis to the public. We encourage feedback and suggestions on NIPH's efforts to address the climate crisis, to ensure good knowledge sharing and that we are fully supporting our stakeholders.

The Cancer Registry of Norway – “a ground for scientific harvesting”

The Cancer Registry of Norway (CRN) has been important in registry-based research in Norway for decades. The use of CRN in combination with other population-based registries and health surveys have been the basis for numerous research projects, which has contributed to fill important knowledge gaps. Researchers at the Norwegian Institute of Public Health and CRN have a long tradition of using these data sources to address research questions of common interests such as e.g. the effect of life style and diet on cancer risk. CRN and the Medical Birth Registry of Norway have co-existed for a long period, making it possible to study cancer incidence and birth characteristics over generations. During the last decades, several new registries such as the Norwegian Prescription Database and the Norwegian Patient Registry have been established, providing opportunities for studying for example drug use and cancer risk and the influence of comorbidities on the development of cancer. In the future, the CRN will be an even more valuable data source when also other population-based registries and health surveys have existed for longer time periods.

Pharmaceutical pollution: Prediction of environmental concentrations from national wholesales data.

The regulation and monitoring of pharmaceutical pollution in Europe lag behind that of more prominent groups. However, the repurposing of sales data to predict surface water environmental concentrations is a promising supplement to more commonly used market-based risk assessment and measurement approaches. The Norwegian Institute of Public Health (NIPH) has since the 1980s compiled the Drug Wholesale Statistics database - covering all sales of both human and veterinary pharmaceuticals to retailers, pharmacies, and healthcare providers. To date, most similar works have focused either on a small subset of Active Pharmaceutical Ingredients (APIs) or used only prescription data, often more readily available than wholesale data, but necessarily more limited. By using the NIPH's product wholesale records, with additional information on API concentrations per product from, we have been able to calculate sales weights per year for almost 900 human and veterinary APIs for the period 2016-2019. In this paper, we present our methodology for converting the provided NIPH data from a public health to an ecotoxicological resource. From our derived dataset, we have used an equation to calculate Predicted Environmental Concentration per API for inland surface waters, a key component of environmental risk assessment. We further describe our filtering to remove ecotoxicological-exempt and data deficient APIs. Lastly, we provide a limited comparison between our dataset and similar publicly available datasets for a subset of APIs, as a validation of our approach and a demonstration of the added value of wholesale data. This dataset will provide the best coverage yet of pharmaceutical sales weights for an entire nation. Moreover, our developed routines for processing 2016-2019 data can be expanded to older Norwegian wholesales data (1974-present). Consequently, our work with this dataset can contribute to narrowing the gap between desk-based predictions of exposure from consumption, and empirical but expensive environmental measurement.

Experience with open schools and preschools in periods of high community transmission of COVID-19 in Norway during the academic year of 2020/2021

BackgroundSchools and preschools have largely remained open in Norway throughout the pandemic, with flexible mitigation measures in place. This contrasts with many other high-income countries that closed schools for long periods of time. Here we describe cases and outbreaks of COVID-19 in schools and preschools during the academic year 2020/2021, to evaluate the strategy of keeping these open with infection prevention control measures in place.MethodsIn this descriptive study, the Norwegian Institute of Public Health initiated systematic surveillance for COVID-19 cases and outbreaks in schools and preschools in October 2020. Data was compiled from the national outbreak alert system VESUV, municipality websites, and media scanning combined with the national emergency preparedness register Beredt C-19. An outbreak was defined as ≥ 2 cases among pupils or staff within 14 days at the same educational setting. Settings were categorized as preschool (1–5-years), primary school (6–12-years), lower secondary school (13–15-years) and upper secondary school (16–18- years). We reported the incidence rate among preschool and school-aged pupils and gave a descriptive overview of outbreaks and included cases per educational setting.ResultsDuring the whole academic year, a total of 1203 outbreaks in preschools and school settings were identified, out of a total of 8311 preschools and schools nationwide. The incidence of COVID-19 in preschool- and school-aged children and the rates of outbreaks in these settings largely followed the community trend. Most of the outbreaks occurred in primary schools (40%) and preschools (25%). Outbreaks across all settings were mostly small (median 3 cases, range 2 to 72), however, 40 outbreaks (3% of total) included 20 or more cases. The larger outbreaks were predominantly seen in primary schools (43%).ConclusionsWe observed few large outbreaks in open schools and preschools in Norway during the academic year of 2020/2021, also when the Alpha variant was predominant. This illustrates that it is possible to keep schools and preschools open even during periods of high community transmission of COVID-19. Adherence to targeted IPC measures adaptable to the local situation has been essential to keep educational settings open, and thus reduce the total burden on children and adolescents.

Differences in comprehending and acting on pandemic health risk information: a qualitative study using mental models

BackgroundA worldwide pandemic of a new and unknown virus is characterised by scientific uncertainty. However, despite this uncertainty, health authorities must still communicate complex health risk information to the public. The mental models approach to risk communication describes how people perceive and make decisions about complex risks, with the aim of identifying decision-relevant information that can be incorporated into risk communication interventions. This study explored how people use mental models to make sense of scientific information and apply it to their lives and behaviour in the context of COVID-19.MethodsThis qualitative study enrolled 15 male and female participants of different ages, with different levels of education and occupational backgrounds and from different geographical regions of Norway. The participants were interviewed individually, and the interview data were subjected to thematic analysis. The interview data were compared to a expert model of COVID-19 health risk communication based on online information from the Norwegian Institute of Public Health. Materials in the interview data not represented by expert model codes were coded inductively. The participants’ perceptions of and behaviours related to health risk information were analysed across three themes: virus transmission, risk mitigation and consequences of COVID-19.ResultsThe results indicate that people placed different meanings on the medical and scientific words used by experts to explain the pandemic (e.g., virus transmission and the reproduction number). While some people wanted to understand why certain behaviour and activities were considered high risk, others preferred simple, clear messages explaining what to do and how to protect themselves. Similarly, information about health consequences produced panic in some interviewees and awareness in others.ConclusionThere is no one-size-fits-all approach to public health risk communication. Empowering people with decision-relevant information necessitates targeted and balanced risk communication.