Date: Mon 1 Apr 2019
Source: GIDEON (Global Infectious Disease Epidemiology Network) [edited]

re: ProMED-mail Tick-borne encephalitis - Norway: cattle
Tick-borne encephalitis (TBE) is one of 8 zoonoses carried by ticks in Norway (the others are anaplasmosis, babesiosis, louping ill, Lyme borreliosis, relapsing fever, rickettsial spotted fever, and tularemia). As displayed in the following graphs, rates of human TBE are considerably lower than those of other tick-borne diseases in Norway, and below TBE rates reported by neighbouring countries. [1-3]

See graphs at

1. Berger S. Infectious Diseases of Norway, 2019. 387 pages , 138 graphs, 858 references. Gideon e-books
2. Berger S. Tick-borne Encephalitis: Global Status, 2019. 89 pages , 49 graphs , 787 references. Gideon e-books
3. Gideon multi-graph tool,
Communicated by:
Prof Steve Berger
Geographic Medicine
Tel Aviv Medical Center
[ProMED-mail thanks Dr Berger for pointing out that TBE virus is not the only tick-borne zoonotic pathogen in Norway. The objective of the author's study, as they defined it, was narrowly focused on TBE in cattle. They chose to analyse unpasteurized cow milk for TBEV RNA and to study the presence of IgG antibodies to TBEV in the same animals. They found evidence for TBE virus infection in cattle in certain areas and pointed out potential risk of infection of humans who consume unpasteurized milk from positive herds. - ProMED Mod.TY]

[HealthMap/ProMED-mail map:
Norway: <>]
Date: Tue 15 Jan 2019
Source: Food Safety News [abridged, edited]

A traditional Norwegian fish dish has been recalled due to a link with a case of botulism. Torpet Fiskeoppdrettsanlegg AS recalled rakfisk due to suspicions that consumption can cause botulism. Rakfisk is a traditional Norwegian fish dish made from trout or char, salted and then fermented for up to a year before being eaten without cooking. The withdrawal applies to all varieties of the product that the company produced in 2018.

Rakfisk was sold via various market stalls in Trondelag, direct delivery from Torpet Fiskeoppdrettsanlegg AS, and via COOP stores in Alen, Brekken, Roros, and Os, according to the Norwegian Food Safety Authority (Mattilsynet). The one reported case is in a person who lives in Trondelag, in central Norway.

The Norwegian Institute of Public Health (Folkehelseinstituttet) said rakfisk from the company is the suspected source for the case of foodborne botulism. People who have rakfisk of this type in the refrigerator should throw the product out and not eat it. Those who have eaten it and have symptoms consistent with botulism should consult a doctor. The agency said toxins can develop under certain adverse conditions in the production of certain foods, such as rakfisk, cured meats, and canned items.

Previous botulism cases in Norway have been associated with rakfisk and home canned meats.

Botulism is a rare but life-threatening condition caused by toxins produced by _Clostridium botulinum_ bacteria. Onset of symptoms varies from a few hours to several days after exposure to the bacteria or toxins. Symptoms can include blurred or double vision, facial muscle weakness, difficulty swallowing, slurred speech and breathing difficulties.  [Byline: Joe Whitworth]
[Given the vehicle, botulism type E is the likely culprit here.

The following was extracted from ProMED-mail Botulism, smoked fish - Finland ex Canada _Clostridium botulinum_ type E is naturally highly prevalent in aquatic environments and fish, leading to a high risk of contamination. The hot-smoking processes are usually too low to eliminate botulinum spores. Growth and toxin production from spores in vacuum-packed smoked fish products with anaerobic atmosphere and limited preservative factors is likely during extended storage at temperatures above 3 deg C (37.4 deg F). Therefore the most important factors controlling _C. botulinum_ growth and toxin production are efficient heat treatments, restricted shelf life, and continuous storage below 3 deg C (37.4 deg F). - ProMED Mod.LL]

[HealthMap/ProMED-mail map of Norway:
Date: Sat 22 Dec 2018
Source: Outbreak News Today [edited]

Officials with the Norwegian Institute of Public Health report seeing an increase in listeriosis cases in December [2018], prompting a warning for high-risk groups.

According to an official notice Friday [21 Dec 2018] (computer translated), 6 cases were reported this month [December 2018] when the country typically sees 1-2 cases a month.

Four of the 6 patients reported in December [2018] are from Hedmark and Oppland. Health officials are working to identify if there is a common food source linked to the increase in cases.

Listeriosis is usually transmitted through food, especially long-life foods that are refrigerated and eaten without further heat treatment. Many of these food products are popular as Christmas foods and can be found at many Christmas parties.

People in the risk groups for listeriosis (i.e., pregnant women, persons with impaired immune systems, and the elderly with impaired general condition) should, as usual, avoid food products that may pose a risk to _Listeria_ infection, says consultant Hans Blystad at the Norwegian Institute of Public Health.

Examples of such food products are
- Rakfisk;
- Products made from unpasteurized milk; and
- Soft and semi-soft cheeses, such as brie, camembert, and other molds, whether or not they are made from pasteurized milk.

Consumption of food contaminated with _L. monocytogenes_ can cause listeriosis, a serious infection that primarily affects older adults, persons with weakened immune systems, and pregnant women and their new-borns. Less commonly, persons outside these risk groups are affected.

Listeriosis can cause fever, muscle aches, headache, stiff neck, confusion, loss of balance, and convulsions, sometimes preceded by diarrhoea or other gastrointestinal symptoms. An invasive infection spreads beyond the gastrointestinal tract. In pregnant women, the infection can cause miscarriages, stillbirths, premature delivery, or life-threatening infection of the newborn.

In addition, serious and sometimes fatal infections occur in older adults and persons with weakened immune systems. Listeriosis is treated with antibiotics. Persons in the higher-risk categories who experience flu-like symptoms within 2 months after eating contaminated food should seek medical care and tell the healthcare provider about eating the contaminated food.
[Hedmark is a county in southeastern Norway, bordering Sweden to the east and Oppland to the west. Hedmark is one of the less urbanized areas in Norway; about half of the inhabitants live on rural land (<>). Hedmark and Oppland are the only Norwegian counties with no coastline. A map of Norwegian counties can be found at <>.

Because _Listeria monocytogenes_, a Gram-positive bacterium that causes listeriosis, can multiply at refrigerator temperatures, _Listeria_-contaminated refrigerated, ready-to-eat products that do not require further cooking before eating, such as smoked salmon or cold-cut meats (e.g., ham), are recognized as potential sources for listeriosis. Unpasteurized milk and cheese and other milk products made from unpasteurized milk are other frequent sources of listeriosis. However, the source in some outbreaks has been contamination with _Listeria_ only after pasteurization.

Serotyping of _L. monocytogenes_ strains, based on variations in the somatic (O) and flagellar (H) antigens, has determined that only 3 (1/2a, 1/2b, and 4b) of the 12 serotypes of _L. monocytogenes_ cause 95% of human cases; serotype 4b is most commonly associated with outbreaks (<>). Genotyping the clinical isolates from the 6 ill people, if they match, will establish that we are dealing with a common-source outbreak, and genotyping isolates from potential sources will establish transmission pathways, if they match the clinical isolates. - ProMED Mod.ML]

[HealthMap/ProMED-mail map:
Norway: <>]
Date: Sat 7 Jul 2018
Source: Outbreak News Today [edited]

The Norway Institute of Public Health reports investigating an outbreak of gastrointestinal bacterium, _Yersinia enterocolitica_ O:9. To date [Sat 7 Jul 2018], 18 people from several counties have been diagnosed with the infection. The patients are between 13 and 60 years old and 60 percent of them are women. They are residents from Troms, Oslo, Akershus, Trøndelag, Vestfold, Rogaland, Nordland, Hordaland and Møre og Romsdal, and are tested in May and early June [2018]. Bacteria with similar DNA profiles have been detected in all 18 individuals. Health and Food Safety officials are trying to determine if there is a common source of infection.

Interviews are conducted with the patients, and samples from the homes are taken to find the source of infection, if possible. "Investigations can be complicated and take time, and in many cases you will not be able to find the source of infection or to clarify if there is a common source", says Solveig Jore Senior Adviser. The most common symptoms of yersiniosis are diarrhoea, fever and abdominal pain, usually of 1-3 weeks duration.

The reservoir for the bacterium is primarily pig. Dogs and cats can also be carriers of the bacterium. _Yersinia_ bacteria mainly contaminate food, usually via infected pork products, contaminated vegetables or salads, and the use of non-disinfected drinking water. Every year, between 40 and 80 cases are reported to the Public Health Institute of Yersiniosis.  Most cases are acquired domestically (70-75 percent of reported cases). [Byline: Robert Herriman]
[The 2 species of _Yersinia_ associated with food-borne disease are _pseudotuberculosis_ and _enterocolitica_. The latter species, can be associated with abdominal pain as a hallmark symptom. As a mesenteric lymphadenitis, yersiniosis can mimic appendicitis but may also cause infections of other sites such as wounds, joints, and the urinary tract.

As noted in the FDA "Bad Bug Book" <>, "Strains of _Y. enterocolitica_ can be found in meats (pork, beef, lamb, etc.), oysters, fish, and raw milk. The exact cause of the food contamination is unknown. However, the prevalence of this organism in the soil and water and in animals such as beavers, pigs, and squirrels, offers ample opportunities for it to enter our food supply.

Poor sanitation and improper sterilization techniques by food handlers, including improper storage, cannot be overlooked as contributing to contamination." Additionally, some strains of these organisms can be associated with blood transfusion-associated illnesses due to an ability to grow at refrigerator temperatures. - ProMED Mod.LL]

[HealthMap/ProMED map available at: Norway:
Date: Wed 29 Nov 2017 06:38
Source: Science Nordic [edited]

Norway is home to roughly 5 million people and nearly a million sheep. Sheep, which wander freely in the Norwegian forests and mountains in the summer, can be infected by _Anaplasma phagocytophilum_, a bacterium carried by ticks that can also infect humans and cattle.

Medical researchers have previously described the tick-borne infection caused by _A. phagocytophilum_ as the most widespread tick-borne infection in animals in Europe.

But its prevalence in Norway in humans is so poorly known that the discovery of a case of anaplasmosis in a man at Stavanger University Hospital merited a just-published report in the December 2017 issue of Lancet Infectious Disease [1]. "This was the 1st confirmed case we have seen in Rogaland County," said Ase Berg, chief attending physician at Stavanger University Hospital, where the infected man was seen.

Although this was the 1st report of the disease, Berg and others say that it is likely that many other people in the county have been infected. In late May 2016, a man came to Stavanger University Hospital reporting that he had experienced recurring attacks of high fever, headaches and achy muscles over the previous 10 days. The doctors who saw him were initially puzzled. They tested him for different blood diseases and cancers and for a number of infectious diseases, such as HIV and hepatitis, but without finding anything. But then the doctors learned that  the man often spent time camping in the woods. These are areas where ticks often infect sheep with _A. phagocytophilum_. The doctors took a sample from his bone marrow and found the bacteria there. The bacterium that causes anaplasmosis can be found by looking at white blood cells under a light microscope, as is shown in this picture. [Photo available at source URL.]

"Between 300,000 and 400,000 lambs are infected here every year," said Professor Snorre Stuen at the Norwegian University of Life Sciences (NMBU), who has studied anaplasmosis for 30 years. In sheep, anaplasmosis infection is called "sjodogg", which translates as tick-borne fever. It has been known for hundreds of years in Norway. The infection can make sheep very ill. Many animals die or are permanently weakened, primarily because the bacterium makes them vulnerable to other infections.

Although there are few reported cases in Norway, it is also known that ticks can transfer _A. phagocytophilum_ to people. The 1st case of anaplasmosis in humans was described in the United States in 1994 by the Norwegian researcher Johan Bakken, who is currently working at the University of Minnesota. It was 1st reported in a human in Europe in 1997. Since that time, more than 15 000 cases of anaplasmosis have been detected in the United States. The American experience means that we know a bit about the course of the disease in humans.

Like the more well-known Lyme disease, anaplasmosis mostly infects people only when the ticks have been attached to their human hosts for more than a day. Symptoms develop 7 to 10 days after the bite and are reminiscent of the flu, with fever, headache and muscle aches. In many cases, the disease clears up by itself, without the infected individual having any serious or lasting ailments. Bakken says the disease is so mild in many people that they think they have a summer cold. "I would estimate that maybe 2 out of 100 have strong enough symptoms that they go to the doctor," he said of his experience in the Midwestern United States.

However, the disease is not completely benign. In just under one of 100 cases reported, the disease is fatal. "As a rule, it's not anaplasmosis itself that kills people, but that the disease makes people more vulnerable to other infections," says Jens Vikse at Stavanger University Hospital.

Nevertheless, people are not routinely tested for anaplasmosis in Norway. The mildness of the symptoms means that few people go to the doctor, even if they have had a fever for several days. Both of these factors mean that health officials don't actually know how prevalent the disease is in Norway. Several surveys in different Norwegian counties found between 14 and 16 percent of those tested had antibodies to the disease, which suggests it is not uncommon.

Ase Berg at Stavanger University Hospital thinks it would be good to test people who work in the woods, as well as people who participate in the sport of orienteering, which involves running through areas that might have a lot of ticks. The researchers believe that it is important for both healthcare professionals and people to be aware that humans can be infected with this bacterium in areas with ticks. If the disease is detected, it can be treated with antibiotics.

But don't worry: The disease does not appear to be chronic, like Lyme disease. So if you are concerned that you might have had it in the past, you don't need to worry that you will have ongoing problems or that you will get it again.  [Byline: Nancy Bazilchuk]

[1. Vikse J, Klos J, Berg A. A travelling camper with a spiking fever, headache, myalgia, hepatitis, and intracellular inclusions, The Lancet Infectious Diseases 2017; 17 (12):1318. DOI: - ProMED Mod.ML ]
[_Anaplasma phagocytophilum_, the causative agent of anaplasmosis (also known as human granulocytic anaplasmosis or HGA), is transmitted to humans in northeastern United States by the same tick (_Ixodes scapularis_ in the northeastern and upper central U.S., _Ixodes pacificus_ in California, _Ixodes ricinus_ in Europe, and _Ixodes persulcatus_ in Europe and Asia). _Ixodes_ also transmit _Borrelia burgdorferi_, the causative agent of Lyme disease and _Babesia microti_, the causative agent of babesiosis, as well as Powassan virus the cause of meningoencephalitis. Typically, the nymph stage of the tick, which is about the size of a poppy seed, transmits these diseases. For a picture of the nymph, see <>. Patients may be concurrently co-infected by these pathogens.

Some individuals infected with _A. phagocytophilum_ do not become ill or experience only very mild symptoms and do not seek medical treatment. The symptoms tend to be most severe in aged or immunosuppressed people. In infected persons who are symptomatic with anaplasmosis, illness onset occurs 5-21 days after a bite from an infected tick. Initial presentation typically includes sudden onset of fever, headache, malaise, and myalgia, often accompanied by thrombocytopenia, leukopenia, and elevated liver transaminases. Approximately 5 to 7 percent of patients require intensive care, and the disease can be fatal. Severe infections can include prolonged fever, shock, confusion, seizures, pneumonitis, renal failure, hemorrhages, and death.

Because _A. phagocytophilum_ are found in the blood stream, infected blood can serve as a vehicle for person-to-person transmission (Centers for Disease Control and Prevention. _Anaplasma phagocytophilum_ Transmitted Through Blood Transfusion -- Minnesota, 2007. MMWR 2008; 57(42): 1145-8. October 2008 [date cited] Available from <>).

Treatment with doxycycline 100 mg twice daily orally or intravenously for 10 days for all symptomatic patients suspected of having anaplasmosis is recommended for a minimal total course of 10 days. This treatment regimen should be adequate therapy for patients with anaplasmosis alone and for patients who are co-infected with Lyme disease, but is not effective therapy for patients who are co-infected with _B. microti_.

Anaplasmosis has been reported in the past in Europe, including Norway
(<> and

Please also see prior ProMED-mail posts Ehrlichiosis, human granulocytic - Sweden

For a further discussion of anaplasmosis, please see my moderator comments in the prior ProMED-mail posts Anaplasmosis - China: (HL) new species, humans, goats, tick-borne and Anaplasmosis - USA: (ME) increased incidence

Rogaland, a coastal county located in southwestern Norway with fjords, beaches, and islands, is the center of the Norwegian petroleum industry (<>). Stavanger, where the patient described in the news report above was hospitalized, is the 3rd-largest urban zone in Norway and the administrative center of Rogaland county.

A map of Rogaland County can be found at
<,+Norway>. - ProMED Mod.ML]

[_Anaplasma phagocytophilum_ has for decades been known to cause the disease tick-borne fever (TBF) in domestic ruminants in _Ixodes ricinus_-infested areas in northern Europe. In recent years, the bacterium has been found associated with Ixodes-tick species more or less worldwide on the northern hemisphere. It has a broad host range, on top of humans; in several mammalian species severe disease may be observed. Fatal cases in animals have been, so far, reported in sheep, cattle, horses, reindeer, roe deer, moose and dogs.

The main disease problems associated with TBF in ruminants are seen in young animals, and individuals purchased from tick-free areas and placed on tick-infested pastures for the 1st time. The most characteristic symptoms in domestic ruminants are high fever, anorexia, dullness, and sudden drop in milk yield. The fever reaction may vary according to the age of the animals, the variant of _A. phagocytophilum_ involved, the host species and immunological status of the host. Abortion in ewes, reduced fertility in rams and reduced weight gain in infected lambs have been observed. For a review addressing _A. phagocytophilum_ in sheep. See ref 1.

1. Stuen S (2016) Tick-Borne Fever (Anaplasma phagocytophilum Infection) in Sheep - A Review. J Vet Med Res 3(5): 1062. - ProMED Mod.AS]

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