Development of prevalence of infectious diseases in Norway

The objective of this master thesis is to investigate the association between the prevalence of infectious diseases and asylum intake in Saltdal municipality and to identify initiated measures of disease treatment, prevention and spreading. Specifically,

Development of prevalence of infectious diseases in Norway over time etc.
According to an article published in the Journal of the Norwegian Medical Association, one of the ravages of the plague that swept through Europe in the mid 14th century was the Black Death. It was one of the most devastating pandemics in human history, peaking in Europe between 1348 and 1350(1, 2).
This infectious disease widely thought to have been an outbreak of plague caused by the bacterium Yersinia pestis, an argument supported by recent forensic research of the analyses of DNA from people in northern and southern Europe (3), although this view has been challenged by a number of scholars(4). The disease was thought to have started in China, travelling along the Silk road and reaching Crimea by 1346. From there, it was probably carried by Oriental rat fleas residing on the black rats that were regular passengers on merchant ships, and then spread throughout the Mediterranean and other parts of Europe.
It was estimated to have killed 30–60% of Europe’s total population. The plague recurred occasionally in Europe until the 19th century, spreading to various lands in europe including England by June 1348, then turned and spread east through Germany and Scandinavia from 1348 to 1350.
An article written by an old Icelandic annals tells that the plague came to Norway, in 1349 with a ship sailing from England that landed at Askøy, then it spread to Bergen. From Bergen, the plague spread rapidly northwards and southwards along the coast and over land to Eastern Norway and remained in Norway for approximately six months (5). According to another article, it provided informations stating that ten epidemics of plague were known to have occurred in Bergen in 1349 to the last epidemic in 1637. Seven of them took place after 1530. During the last five epidemics in Bergen 12,900-14,500 people died of the plague in the course of 70 years, which was twice the population of the city(6).
Based on a report by Absalon Pederssøn, a citizen of Bergen, in his describes the onset of the epidemic in Bergen between 1565-67, and reported the deaths from day to day. According to the diary, he stated that the plague was brought to Bergen on about 10th August 1565 by a ship from Danzig.
And that a total of 1,500 people died of bubonic plague in Bergen, which was about 21-25% of its population. The peaks of the epidemic occurred during the autumn months (7).
The plague was known to have left a horrific and distressing long lasting impact on the history of Europe in terms of social, political, and economical developments as over centuries it repeatedly hit cities and villages, with devastating demographic consequences(5). As a result, for areas of Europe where estimates are available, it was documented that by 1400, the population in these areas decreased to less than half of what it was before the Black Death. The sequence of plague epidemics continued in Western Europe until the mid-seventeenth century. The population of Europe was kept low during this whole period and only started to increase substantially again after the mid-seventeenth century(8, 9).

According to an article published on the webpage of the institute of public health in Norway(folkehelseinstutite) it showed that the fight against infectious diseases, especially cholera and typhus, were one of the most common infectious diseases that affected the Norwegian population in the 18th century with several episodes of epidemics, cholera been the worst having its last epidemics occurrence in the 1840s.
Cholera was localized in Asia until 1817, when the first pandemic spread from India to several other regions of the world. After this appearance, six additional major pandemics occurred during the 19th and 20th centuries (10). It is caused by the bacteria Vibrio cholerae, which basic symptoms are profused watery diarrhea which often leads to dehydration and eventually death if left untreated.
This infectious disease came to Norway for the first time in autumn 1832. The outbreak was limited to the city of Drammen and some densely populated areas on the Drammen fjord, with a low mortality of about 80 persons, 59 of this deaths were in Drammen (11).

The City of Kristiansand had a quarantine station and hospital at Odderøy island from 1804. The quarantine stations were studied and the number of deaths were also compared in the different cities.
During 1832-33, 1833 and 1857 the Drammen community had registered 544 cholera patients; 336 died. Kristiansand had only 15 deaths from 1833, 1853 and 1866 the statics include the deaths recorded in the quarantine hospital. In comparism to other cities, Kristiansand had few deaths (12). On the 10th of December 1848, a big cholera epidemic broke out in Bergen. It lasted until April 1849, leading to about 605 deaths. The cholera spread by contact from person to person. How it came to Bergen, and how it was introduced into the population has till date been open to doubt. Primary sources have been studied and compared with contemporary medical reports. Reports showed that a schooner from the Dutch city of Vlaardingen brought the cholera to Bergen. (13).During the great cholera epidemic in Bergen in 1848-49, three cholera hospitals were established. Records from the three hospitals was found and studied. Of the 1,024 cholera patients in the city, 707 were hospitalized, and of these 430 (60.8 per cent) died. (14).
During the cholera epidemic in Bergen 1848 – 49, 712 died. Almost 150 years after the Bergen’s epidemic, the microbiologist Per Oeding (1916 – 2003) published information that the infection was likely to come from a shipwreck. Skonnerten Magdalene Christine, a resident of Bergen, had a passenger who died on board. The ship came from Vlaardingen, near Rotterdam, which had cholera mite. The quarantine commission was not sure that the death was due to cholera, but the vessel had quarantines for six days after arrival without more sick people. Fresh contaminants among the crew can later have infected contact persons in the city.

The cholera hit Bergen on December 10, 1848. First, Anne Marie Kinde, resident of the Skivebakken, was ill. According to one version, she was infected when she washed clothes after a deceased, colossal sailor

After the eruption on December 10, 1848, the number of infected persons increased from week to week. In week 2, mortality was 88% – almost nine out of ten infected deaths, because the disease hit the elderly and malnourished residents of the poverty alleys. The “Sugar House” had previously served as an epidemic lasarette, among other things in 1773. 121 patients were enrolled, 84 registered dead (last deaths February 7), 37 printed as fresh.
There were 226 cholera patients, 136 of whom were reported dead (last 15 March), 90 printed as fresh. (

In week 7, the number of infected people reached a peak of 198 new cases but a mortality rate of only 47%, probably because the disease had reached a residential area where people had greater resilience, while some were admitted to a suspicion that proved to be error.

Statistics from cities along the Norwegian coast in the 19th century show that Kristiansand had clearly lower mortality for cholera than other cities with lively shipping. The sickness was also low. It is important to point out the importance of the early established and apparently well-functioning quarantine station and quarantine arena on Odderøya. Probably the organization and the practical measures surrounding the quarantine activities outside the city gave early experience and knowledge of importance for measures and regulations against cholera, and partly against other infectious diseases such as typhus, also inside the city. For example, we have the impression that an epidemic in Kristiansand with infection from the Steamship Constitution was stopped by effective measures.

Kristiansand had around 1850 relatively fewer sick and died of cholera than other Norwegian cities

One reason is probably the quarantine station and the lasaret on Odderøya, created in 1804, while good measures and practices in the city

In the 18th century, smallpox was the third most significant epidemic in Norway and the rest of Europe. The principle of variolation had been known for a long time, but Edward Jenner’s “vaccination”, using fluid from cowpox instead of smallpox vesicles, represented a much safer method. His publication in 1798, “An Inquiry into the Causes and Effects of Variolae Vaccinae”, convinced the medical society and the general population that the inoculation technique was safe and efficient.

The method was implemented in Great Britain and thereafter in many European countries. In Norway, which was under Danish rule at the time, vaccination was adopted sporadically from 1800 and made mandatory by law in 1810. The history of smallpox vaccination is a success story. It would, however, take some 170 years before the World Health Assembly could declare smallpox eradicated on 8 May 1980.

In the 1970s, smallpox had been a non-existing disease in Europe for several years. However, to ensure world-wide eradication of the disease, it was of utmost importance to maintain national vaccination programmes in developed countries as long as the disease could still be spread by travellers. In 1976, health authorities eventually found it safe to abolish mandatory vaccination against smallpox in Norway, and in 1980 the World Health Assembly finally declared the disease fully eradicated.

Leprosy ravaged especially in Western Norway. Patients were isolated in their own leprosy hospital.
1856 – A national leprosy registry was established in Bergen as the first disease registry in the world
Leprosy is one of the oldest and most terrifying plagues mankind has had to endure. Its victims were always stigmatized and expelled from society. During the 18th and 19th centuries most of Europe was leprosy free. In Norway, however, the disease was highly prevalent, especially in the western and northern regions.

The high incidence was probably the main reason for establishing the first national disease registry in the world in Norway. In 1856, the government decided that all cases of leprosy should be registered, and that all registrations were to be sent to the chief physician in Bergen. The idea was to identify and isolate all diseased persons thus preventing further spreading of the disease.

Sexually transmitted diseases were widespread, later was a distinction between gonorrhoea and syphilis.
Towards the end of the 19th century, tuberculosis became the big “killer”, while the incidence of leprosy and drastically declined.
Apart from the diseases listed above, various stomach diseases, blood disorders (dysentery) and diarrhea occurred.

Up to 10 percent of all infants died. Childhood diseases were often fatal. When the law on vaccination against cups came in 1810, you were given control of the “child cops”, which was the most serious childhood disease. The law was not enforced strictly at the beginning, but when an injunction certificate was issued on confirmation, marriage and session, the vaccination of children increased.

Only at the end of the 19th century were the microbes discovered and it opened for preventative measures. There had previously been disagreement among doctors about what was caused by “infection” and what had other causes. The terms of infection were unclear, but during cholera epidemics it was understood that it was about infection or transmission between humans.

Due to the high child mortality, life expectancy was slightly over 40 years in the first half of the 19th century.

still improving in public health
Folkehelsen gradually became better throughout the 1900s, despite World War II 1940-1945. In particular, the number of infections significantly decreased. An example is tuberculosis, see Figure 2. The mortality rate of tuberculosis was very high around 1900, but then slowed steadily over the next 50 years. Most of the decline came before we received vaccine and drug treatment, mainly due to improved living standards, housing conditions, nutrition and hygiene. Figure 2 shows that the mortality among the girls was greater than among the boys, but the difference decreased and disappeared after 1945.

The figure above shows Mortality of tuberculosis, between girls and boys 15-19 years in the period 1875 to 1960. Source: Statistics Norway, Mortality and its causes in Norway 1856-1955, Oslo 1961.

Vaccines eradicated childhood diseases
During the 19th century a number of vaccines came. From 1942 the diphtheria vaccine became available and the effect was immediate. Diphtheria was a common childhood disease, and in 1940-43 it was a major epidemic. Another example is poliomyelitis. The last major epidemic occurred in 1951, when 2100 cases were registered (Flugsrud, 2006). In the autumn of 1956 the polio vaccination started in Norway.

Eventually, there were several new vaccines, especially for children, and the childhood vaccination program grew. Soon all the most feared childhood diseases were almost extinct. The most important were polio and diphtheria, but also measles and pertussis. Rubella vaccine was introduced in the 1978 child welfare program.
The infection rate where incredible high until the medical breakthrough of antibiotics.
The first antibiotic, penicillin, came in the 1940s and was especially used in the treatment of infections. Then followed a series of similar drugs for different types of infection treatment.

Aids appeared as a previously unknown disease in the early 1980s. Norway was in the early stages of preventive work in the high risk groups. The HIV virus was detected and the HIV test available around 1985. HIV can today be treated with drugs that fight infection but without the virus being completely removed from the body.

From tuberculosis to myocardial infarction
At the same time as the tuberculosis went back, the incidence and mortality of chronic diseases, especially cardiovascular disease, increased. This is often called the epidemiological transition.

Cardiovascular disease takes over towards the end of the 19th century
Towards the end of the 19th century, the disease is characterized by chronic diseases. Cardiovascular disease began to dominate the infections disease world.

By the millennium, new treatment and prevention have made the mortality of cardiovascular disease down, but these diseases remain one of our greatest public health challenges.

Lifestyle diseases became a new term in the second half of the 19th century, and especially smoking and cholesterol-increasing fat came in the spotlight as risk factors for cardiovascular disease.

Cardiovascular disease takes over towards the end of the 20th century
Towards the end of the 20th century, the disease is characterized by chronic diseases. Cardiovascular disease dominates. Due to increased life expectancy, there are also several who live long with chronic diseases.

By the millennium, new treatment and prevention have made the mortality of cardiovascular disease down, but these diseases remain one of our greatest public health challenges.

Lifestyle diseases became a new term in the second half of the 20th century, and especially smoking and cholesterol-increasing fat came in the spotlight as risk factors for cardiovascular disease.

The development of the welfare state beyond the 1900s has contributed to the fact that infant mortality is now among the lowest in our part of the world – less than 0.3 per cent.

This can be attributed to several reasons: Better nutrition and living conditions, better education and economics, better treatment opportunities and, to some extent, preventive health care, especially the vaccination services through health centers. All children are offered free vaccines, and the offer is voluntary. The coverage rate for most vaccines is very high.

Fight against tuberculosis
Tuberculosis studies were initiated to detect sources of infection and stop infectious spread. The state screen shot control came into operation from 1943. With specially-tuned buses and boats with X-ray equipment, the screen surveys visited every small hook of the country at regular intervals. The surveys were maintained until the 1970s.

As the tuberculosis went back, Screenshot Control changed its name to State Health Surveys and directed to cardiovascular disease instead (Bjartveit, 1997). Similarly, the voluntary organizations also changed their work area.

The fight against tuberculosis included, among other things, the Norwegian Women’s Sanitation Association, which was founded in 1896, and not least the National Association Against Tuberculosis, which conducted extensive information activities and was responsible for several tuberculosis hospitals.

The annual population growth in Norway has been just over 1 per cent in recent years. About one third is due to birth surplus, while the rest is due to net immigration.

Immigration to Norway has increased sharply in recent decades. Today, immigrants and their descendants account for around 14 percent of the population. This percentage will increase strongly in the years to come (Brunborg & Tønnesen, 2013).

How is the HIV situation in Norway?
In total, 5843 were diagnosed with HIV by the end of 2015 (3948 men and 1859 women). It is estimated that by 2016 there are an estimated 4500-5000 people living with HIV infection in Norway.

After a stable spread of infection during the 1990s, the number of HIV victims detected has increased in the 2000s. This is due mainly to more HIV-positive immigrants who have been infected in their former home country prior to arrival in Norway and a significant increase in infection among men who have sex with men (MSM). Many MSM are sneezed at arenas for random or anonymous sex.

Immigrants account for almost one third of those who have been diagnosed with HIV infection in Norway. Most come from conflict areas in Central and Eastern Africa, as well as from Southeast Asia. Heterosexual spread of infection among persons residing in Norway is still relatively rare. Most in this group are men who are infected abroad, especially in Thailand. There is little news of injecting abusers in Norway.

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