Gastroenteritis in Norwegian primary care - Time trends and a large waterborne outbreak

Gastroenteritis is a common term for acute infection of the gastrointestinal tract and includes several conditions and specific infections. Gastroenteritis has to a great extent caused disease and death in humans through our history. Even the very foundation of epidemiology can be traced back to John Snow's work on identifying drinking water as source of the cholera epidemic in London in 1854. Gastroenteritis still occurs frequently in the community, but most people in our part of the world experience self-limiting symptoms and therefore only a small proportion seek the health care services. Of those seeking medical attention, only a few submit stool samples for microbiological diagnostics, and only those who are diagnosed with a notifiable microbe are included in the statistics of the notification systems of infectious diseases. The clinical features of gastroenteritis vary from asymptomatic cases to fatal disease, but diarrhea is common in cases who develop symptoms. The clinical features in the individual gastroenteritis patient can give a hint as to whether there is a viral or bacterial cause. Correspondingly, using existing knowledge about seasonal variation and the epidemiology of the specific infections may give an indication of probable microbiological cause in gastroenteritis patients at group level. This is useful knowledge because laboratory verified diagnoses are rare. Our study of consultations for gastroenteritis in Norwegian primary care during a 10-year period shows a contact pattern similar to what characterizes viral gastroenteritis: Most consultations took place in the winter and children and young adults dominated among the patients. The findings contribute to increased knowledge of the normal situation regarding gastroenteritis patients’ use of health care services. Since antibiotics became widely available in the years following World War II, antibiotic treatment has been central to the treatment of many infectious diseases. Gastroenteritis has been an exception, both because most are viral and because antibiotics only to a small extent have been shown to shorten the course of the disease and relieve symptoms also in most bacterial gastroenteritis. Antimicrobial resistance in bacteria causing gastroenteritis represent a growing concern in a European and global context, although the current situation in Norway is more favorable. Transmission between animals and humans, either directly or indirectly via food, makes resistance in zoonoses and food-borne microbes particularly challenging. Our study of antibiotic use in gastroenteritis in the Norwegian primary health care service over a 10-year period shows that antibiotics are rarely used compared with other countries. Further, there has been an even more favorable development after 2012 with a decrease in the use of resistance-driving antibiotics such as fluoroquinolones and macrolides. Gastroenteritis tends to appear as outbreaks of various magnitude and public health importance. The outbreaks occur and spread either via direct contact between humans, directly between humans and animals, or as food-borne outbreaks where the microbe spreads to humans via food or drinking water. Gastroenteritis caused by the foodborne infection campylobacteriosis is an example of the latter, and in June 2019, more than 1 500 in the community became acutely ill during a major waterborne outbreak of Campylobacter infection in Askøy. Our population-based study of acute gastroenteritis during the outbreak shows a broader spectrum of symptoms, with less bloody stools and more tiredness and joint pain than previously described in laboratory-verified sporadic cases of Campylobacter infection. The study sheds light on the cases of gastroenteritis that occur in the interface between how they appear in the community, in the health care services, in the notification systems, and not least in the research literature.Doktorgradsavhandlin

Consultations for gastroenteritis in general practice and out-of-hours services in Norway 2006–15

Background: Most of the patients with gastroenteritis seeking health care services are managed in primary care; yet, little is known about these consultations. Syndromic-based surveillance of gastrointestinal infections is used in several countries, including Norway. Aim: To investigate the extent of, and explore characteristics associated with, consultations for gastroenteritis in primary care and to compare consultations in daytime general practice and out-of-hours (OOH) services in Norway. Design and Setting: Registry-based study using reimbursement claims data from all consultations in general practice and OOH services in Norway over the 10-year period, 2006–15. Methods: The main outcome variable was whether the consultation took place in general practice or OOH services. Possible associations with patient age and sex, time and use of point-of-care C-reactive protein (CRP) testing and sickness certificate issuing were investigated. Results: Gastroenteritis consultations (n = 1 281 048) represented 0.9% of all consultations in primary care (n = 140 199 637), of which 84.4% were conducted in general practice and 15.6% in OOH services. Young children and young adults dominated among the patients. Point-of-care CRP testing was used in 36.1% of the consultations. Sickness certificates were issued in 43.6% of consultations with patients in working age. Age-specific time variations in consultation frequencies peaking in winter months were observed. Conclusions: The proportion of gastroenteritis consultations was higher in the OOH services when compared with daytime general practice. Young children and young adults dominated among the patients. The seasonal variation in consultation frequency is similar to that shown for gastroenteritis caused by norovirus.publishedVersio

Consultations and antibiotic treatment for urinary tract infections in Norwegian primary care 2006–2015, a registry-based study

Background Extensive use of antibiotics and the resulting emergence of antimicrobial resistance is a major health concern globally. In Norway, 82% of antibiotics is prescribed in primary care and one in four prescriptions are issued for the treatment of urinary tract infections (UTI). The aim of this study was to investigate time trends in antibiotic treatment following a consultation for UTI in primary care. Methods For the period 2006–2015 we linked data from the Norwegian Registry for Control and Payment of Health Reimbursements on all patient consultations for cystitis and pyelonephritis in general practice and out-of-hours (OOH) services, and data from the Norwegian Prescription Database on all dispensed prescriptions of antibiotics. Results Altogether 2,426,643 consultations by attendance for UTI took place in the study period, of these 94.5% for cystitis and 5.5% for pyelonephritis. Of all UTI consultations, 79.4% were conducted in general practice and 20.6% in OOH services. From 2006 to 2015, annual numbers of cystitis and pyelonephritis consultations increased by 33.9 and 14.0%, respectively. The proportion of UTI consultations resulting in an antibiotic prescription increased from 36.6 to 65.7% for cystitis, and from 35.3 to 50.7% for pyelonephritis. These observed changes occurred gradually over the years. Cystitis was mainly treated with pivmecillinam (53.9%), followed by trimethoprim (20.8%). For pyelonephritis, pivmecillinam was most frequently used (43.0%), followed by ciprofloxacin (20.5%) and sulfamethoxazole-trimethoprim (16.3%). For cystitis, the use of pivmecillinam increased the most during the study period (from 46.1 to 56.6%), and for pyelonephritis, the use of sulfamethoxazole-trimethoprim (from 11.4 to 25.5%) followed by ciprofloxacin (from 18.2 to 23.1%). Conclusions During the 10-year study period there was a considerable increase in the proportion of UTI consultations resulting in antibiotic treatment. Cystitis was most often treated with pivmecillinam, and this proportion increased during the study period. Treatment of pyelonephritis was characterized by more use of broader-spectrum antibiotics, use of both sulfamethoxazole-trimethoprim and ciprofloxacin increased during the study period. These trends, indicative of enduring changes in consultation and treatment patterns for UTIs, will have implications for future antibiotic stewardship measures and policy.publishedVersio

Clinical features of gastroenteritis during a large waterborne Campylobacter outbreak in Askøy, Norway

Purpose: Outbreaks of Campylobacter infection are common, but studies exploring the clinical features of acute illness in the outbreak setting are scarce in existing literature. The main purpose of the present study was to investigate the clinical features of self-reported acute illness in gastroenteritis cases during a large waterborne Campylobacter outbreak in Askøy municipality, Norway, in 2019. Methods: A web-based self-administered questionnaire, and invitation to participate was sent by the municipality of Askøy as text message to mobile phones using the municipality’s warning system to the inhabitants during the ongoing outbreak. Results. Out of 3624 participants, 749 (20.7%) were defined as cases, of which 177 (23.6%) reported severe gastroenteritis. The most common symptoms were loose stools (90.7%), abdominal pain (89.3%) and diarrhea (88.9%), whereas 63.8% reported fever, 50.2% joint pain and 14.2% bloody stools. Tiredness, a symptom non-specific to gastroenteritis, was the overall most common symptom (91.2%). Conclusion: About one in four of the cases reported symptoms consistent with severe gastroenteritis. We found more joint pain and less bloody stools than reported in published studies of laboratory confirmed campylobacteriosis cases. Tiredness was common in the current study, although rarely described in previous literature of acute illness in the outbreak setting.publishedVersio

Antibiotics for gastroenteritis in general practice and out-of-hours services in Norway 2006-15

Background When patients with gastroenteritis (GE) seek health care, they are generally managed in primary care. Little is known about the use of antibiotic treatment in these cases. Objective The aim of this study was to investigate time trends and patient characteristics associated with antibiotic treatment for GE in Norwegian primary care in a 10-year period. Methods We linked data from two nationwide registries, reimbursement claims data from Norwegian primary care (the KUHR database) and The Norwegian Prescription Database, for the period 2006–15. GE consultations were extracted, and courses of systemic antibiotics dispensed within 1 day were included for further analyses. Results Antibiotic treatment was linked to 1.8% (n = 23 663) of the 1 279 867 consultations for GE in Norwegian primary care in the period 2006–15. The proportion of GE consultations with antibiotic treatment increased from 1.4% in 2006 to 2.2% in 2012 and then decreased to 1.8% in 2015. Fluoroquinolones (28.9%) and metronidazole (26.8%) were most frequently used. Whereas the number of fluoroquinolones courses decreased after 2012, the number of metronidazole courses continued to increase until year 2015. The antibiotic treatment proportion of GE consultations was lowest in young children and increased with increasing age. Conclusion Antibiotic treatment is infrequently used in GE consultations in Norwegian primary care. Although there was an overall increase in use during the study period, we observed a reduction in overall use after year 2012. Young children were treated with antibiotics in GE consultations less frequent than older patients.publishedVersio

The associations between different types of infections and circadian preference and shift work

Disturbed sleep and circadian disruption are reported to increase the risk of infections. People with an evening circadian preference and night workers typically report insufficient sleep, and the aims of the present study were to investigate possible associations between various types of infections and circadian preference and shift work status. Data were collected from an online cross-sectional survey of 1023 participants recruited from the Norwegian practice-based research network in general practice – PraksisNett. The participants completed questions about circadian preference (morning type, intermediate type, evening type), work schedule (day work, shift work without nights, shift work with night shifts), and whether they had experienced infections during the last three months (common cold, throat infection, ear infection, sinusitis, pneumonia/bronchitis, COVID-19, influenza-like illness, skin infection, gastrointestinal infection, urinary infection, venereal disease, eye infection). Data were analyzed with chi-square tests and logistic regression analyses with adjustment for relevant confounders (gender, age, marital status, country of birth, children living at home, and educational level). Results showed that evening types more often reported venereal disease compared to morning types (OR = 4.01, confidence interval (CI) = 1.08–14.84). None of the other infections were significantly associated with circadian preference. Shift work including nights was associated with higher odds of influenza-like illness (OR = 1.97, CI = 1.10–3.55), but none of the other infections. In conclusion, neither circadian preference nor shift work seemed to be strongly associated with risk of infections, except for venereal disease (more common in evening types) and influenza-like illness (more common in night workers). Longitudinal studies are needed for causal inferences.publishedVersio

Rastløse bein – en studie fra allmennpraksis

BAKGRUNN Forekomsten av rastløse bein er rundt 5–10 % blant voksne i den generelle befolkningen. Få studier er gjort om forekomsten blant pasienter som oppsøker fastlege. Det er også få studier om sammenheng med andre vanlige plager som irritabel tarm, kronisk utmattelse eller kronisk muskel- og ryggsmerte. MATERIALE OG METODE Studien ble gjennomført som en spørreskjemaundersøkelse ved legekontorer på Sør- og Vestlandet høsten 2017 og våren 2018, der pasienter som ventet på time hos fastlegen fortløpende ble invitert til å delta. 2 634 personer deltok (62,2 % kvinner, gjennomsnittsalder 49,6 år). Svarprosenten var 86,8. Rastløse bein ble definert basert på internasjonale kriterier. Assosiasjoner mellom rastløse bein og irritabel tarm, kronisk utmattelse og kronisk muskel- og ryggsmerte ble analysert med khikvadrattester og logistisk regresjon. RESULTATER OG FORTOLKNING Andelen pasienter med rastløse bein var 14,3 %. Blant pasientene med rastløse bein rapporterte 44,8 % at symptomene var moderate til veldig plagsomme, og 85,8 % at de ikke brukte medikamenter for dette. Andelen pasienter med rastløse bein var signifikant høyere blant pasienter med irritabel tarm (21,8 % versus 13,6 %, p = 0,009), kronisk utmattelse (18,2 % versus 13,1 %, p = 0,003) og kronisk muskel- og ryggsmerte (23,2 % versus 12,2 %, p < 0,0005). Fastleger bør være oppmerksomme på at mange pasienter har rastløse bein og at tilstanden er assosiert med andre vanlige plager. HOVEDFUNN Forekomsten av rastløse bein var 14,3 % blant pasienter som oppsøker fastlegen. Rundt halvparten av dem oppga mye og hyppige plager, men et fåtall benyttet medikamentell behandling. Rastløse bein var hyppigere blant pasienter med andre plager som irritabel tarm (justert oddsratio (OR) 1,73), kronisk utmattelse (OR 1,48) og kronisk muskel- og ryggsmerte (OR 2,06), sammenliknet med pasienter uten disse tilstandene.publishedVersio

Gastroenteritis in Norwegian primary care - Time trends and a large waterborne outbreak

Gastroenteritis is a common term for acute infection of the gastrointestinal tract and includes several conditions and specific infections. Gastroenteritis has to a great extent caused disease and death in humans through our history. Even the very foundation of epidemiology can be traced back to John Snow's work on identifying drinking water as source of the cholera epidemic in London in 1854. Gastroenteritis still occurs frequently in the community, but most people in our part of the world experience self-limiting symptoms and therefore only a small proportion seek the health care services. Of those seeking medical attention, only a few submit stool samples for microbiological diagnostics, and only those who are diagnosed with a notifiable microbe are included in the statistics of the notification systems of infectious diseases. The clinical features of gastroenteritis vary from asymptomatic cases to fatal disease, but diarrhea is common in cases who develop symptoms. The clinical features in the individual gastroenteritis patient can give a hint as to whether there is a viral or bacterial cause. Correspondingly, using existing knowledge about seasonal variation and the epidemiology of the specific infections may give an indication of probable microbiological cause in gastroenteritis patients at group level. This is useful knowledge because laboratory verified diagnoses are rare. Our study of consultations for gastroenteritis in Norwegian primary care during a 10-year period shows a contact pattern similar to what characterizes viral gastroenteritis: Most consultations took place in the winter and children and young adults dominated among the patients. The findings contribute to increased knowledge of the normal situation regarding gastroenteritis patients’ use of health care services. Since antibiotics became widely available in the years following World War II, antibiotic treatment has been central to the treatment of many infectious diseases. Gastroenteritis has been an exception, both because most are viral and because antibiotics only to a small extent have been shown to shorten the course of the disease and relieve symptoms also in most bacterial gastroenteritis. Antimicrobial resistance in bacteria causing gastroenteritis represent a growing concern in a European and global context, although the current situation in Norway is more favorable. Transmission between animals and humans, either directly or indirectly via food, makes resistance in zoonoses and food-borne microbes particularly challenging. Our study of antibiotic use in gastroenteritis in the Norwegian primary health care service over a 10-year period shows that antibiotics are rarely used compared with other countries. Further, there has been an even more favorable development after 2012 with a decrease in the use of resistance-driving antibiotics such as fluoroquinolones and macrolides. Gastroenteritis tends to appear as outbreaks of various magnitude and public health importance. The outbreaks occur and spread either via direct contact between humans, directly between humans and animals, or as food-borne outbreaks where the microbe spreads to humans via food or drinking water. Gastroenteritis caused by the foodborne infection campylobacteriosis is an example of the latter, and in June 2019, more than 1 500 in the community became acutely ill during a major waterborne outbreak of Campylobacter infection in Askøy. Our population-based study of acute gastroenteritis during the outbreak shows a broader spectrum of symptoms, with less bloody stools and more tiredness and joint pain than previously described in laboratory-verified sporadic cases of Campylobacter infection. The study sheds light on the cases of gastroenteritis that occur in the interface between how they appear in the community, in the health care services, in the notification systems, and not least in the research literature

Respiratory tract infections in Norwegian primary care 2006–2015: a registry-based study

Objective Examine characteristics and time trends of respiratory tract infection (RTI) consultations in Norwegian primary care and compare consultations in daytime general practice and out-of-hours (OOH) services. Design Registry-based study using reimbursement claims data. Setting All in-person primary care consultations during 2006–2015. Patients All patients visiting primary care during the study period. Main outcome measures The main outcome variable was RTI consultations. Differences regarding service type (general practice or OOH services) and changes over time were investigated. We report associations with patient age and sex, season, point-of-care C-reactive protein (CRP) test use, and sickness certificate issuing. Results RTI consultations (n = 16 304 777) represented 11.6% of all consultations (N = 140 199 637) in primary care over the ten-year period. The annual number of RTI consultations per 1000 inhabitants decreased from 335 to 314, while the number of consultations for any reason increased. Of RTI consultations, 83.2% occurred in general practice. OOH services had a higher proportion of RTI consultations (21.4%) compared with general practice (10.6%). Young children (0–4 years) represented 18.9% of all patients in RTI consultations. CRP testing was used in 56.2% of RTI consultations, and use increased over time. Sickness certificates were issued in 31.9% of RTI consultations with patients of working age (20–67 years). Conclusion Most RTI consultations occurred in general practice, although the proportion was higher in OOH services. Laboratory testing and/or issuing of sickness certificates were part of most consultations. This could be an important reason for seeking health care.publishedVersio

Consultations for gastroenteritis in general practice and out-of-hours services in Norway 2006–15

Background: Most of the patients with gastroenteritis seeking health care services are managed in primary care; yet, little is known about these consultations. Syndromic-based surveillance of gastrointestinal infections is used in several countries, including Norway. Aim: To investigate the extent of, and explore characteristics associated with, consultations for gastroenteritis in primary care and to compare consultations in daytime general practice and out-of-hours (OOH) services in Norway. Design and Setting: Registry-based study using reimbursement claims data from all consultations in general practice and OOH services in Norway over the 10-year period, 2006–15. Methods: The main outcome variable was whether the consultation took place in general practice or OOH services. Possible associations with patient age and sex, time and use of point-of-care C-reactive protein (CRP) testing and sickness certificate issuing were investigated. Results: Gastroenteritis consultations (n = 1 281 048) represented 0.9% of all consultations in primary care (n = 140 199 637), of which 84.4% were conducted in general practice and 15.6% in OOH services. Young children and young adults dominated among the patients. Point-of-care CRP testing was used in 36.1% of the consultations. Sickness certificates were issued in 43.6% of consultations with patients in working age. Age-specific time variations in consultation frequencies peaking in winter months were observed. Conclusions: The proportion of gastroenteritis consultations was higher in the OOH services when compared with daytime general practice. Young children and young adults dominated among the patients. The seasonal variation in consultation frequency is similar to that shown for gastroenteritis caused by norovirus