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1.  Increases in the completeness of disease records in dairy databases following changes in the criteria determining whether a record counts as correct 
The four Nordic countries: Denmark (DK), Finland (FIN), Norway (NO) and Sweden (SE), all have national databases in which mainly records of treated animals are maintained. Recently, the completeness of locomotor disorder records in these databases has been evaluated using farmers’ recordings as a reference level. The objective of the present study was to see how previous estimates of completeness figures are affected by the criteria determining whether a recording in the database is to be judged correct. These demands included date of diagnosis and disease classification. In contrast with the previous study, a period of time between the date of disease recording in the database and by the farmer was allowed. Further, the calculations were brought to bear on individual locomotor diagnoses instead of a common locomotor disease complex code.
Randomly selected dairy herds (≥ 15 cows) were invited to participate. During two 2-month periods in 2008 the farmers recorded the diseases they observed on the farm and their recordings constituted a farmer database (FD). These recordings were compared to disease recordings in the National Databases (ND). Earlier calculations of completeness for locomotor complex cases assuming an exact match on date were compared with ±7 day and ±30 day discrepancies calculated in this study.
The farmers in DK, FIN, NO and SE recorded 426, 147, 97 and 193 locomotor disorders, respectively. When a window of ±7 days was allowed there was a relative increase in completeness figures lying in the range of 24–100%. Further increases were minor, or non-existent, when the window was expanded to ±30 days. The same trend was seen for individual diagnoses.
In all four of the Nordic countries a common pattern can be observed: a further increase in completeness occurs when individual locomotor diagnoses recorded by the farmer are permitted to match any locomotor diagnosis recorded in the ND. Completeness increased when both time span and different diagnoses within the locomotor complex were allowed.
PMCID: PMC3538600  PMID: 23206729
Nordic dairy disease databases; Validation; Completeness; Farmer disease recording; Locomotor disorders
2.  Cumulative Risk of Bovine Mastitis Treatments in Denmark, Finland, Norway and Sweden 
Acta Veterinaria Scandinavica  2004;45(4):201-210.
Data from the national dairy cow recording systems during 1997 were used to calculate lactation-specific cumulative risk of mastitis treatments and cumulative risk of removal from the herds in Denmark, Finland Norway and Sweden. Sweden had the lowest risk of recorded mastitis treatments during 305 days of lactation and Norway had the highest risk. The incidence risk of recorded mastitis treatments during 305 days of lactation in Denmark, Finland, Norway and Sweden was 0.177, 0.139, 0.215 and 0.127 for first parity cows and 0.228, 0.215, 0.358 and 0.204 for parities higher than three, respectively. The risk of a first parity cow being treated for mastitis was almost 3 times higher at calving in Norway than in Sweden. The period with the highest risk for mastitis treatments was from 2 days before calving until 14 days after calving and the highest risk for removal was from calving to 10 days after calving in all countries.
The study clearly demonstrated differences in bovine mastitis treatment patterns among the Nordic countries. The most important findings were the differences in treatment risks during different lactations within each country, as well as differences in strategies with respect to the time during lactation mastitis was treated.
PMCID: PMC1820994  PMID: 15663080
Data recording; mastitis treatment; Nordic countries; dairy herds; cumulative incidence risk; culling
3.  The Nordic Arthroplasty Register Association 
Acta Orthopaedica  2009;80(4):393-401.
Background and purpose The possibility of comparing results and of pooling the data has been limited for the Nordic arthroplasty registries, because of different registration systems and questionnaires. We have established a common Nordic database, in order to compare demographics and the results of total hip replacement surgery between countries. In addition, we plan to study results in patient groups in which the numbers are too small to be studied in the individual countries.
Material and methods Primary total hip replacements (THRs) from 1995–2006 were selected for the study. Denmark, Sweden, and Norway contributed data. A common code set was made and Cox multiple regression, with adjustment for age, sex, and diagnosis was used to calculate prosthesis survival with any revision as endpoint.
Results 280,201 operations were included (69,242 from Denmark, 140,821 from Sweden, and 70,138 from Norway). Females accounted for 60% of the patients in Denmark and Sweden, and 70% in Norway. Childhood disease was the cause of 3.1%, 1.8%, and 8.7% of the operations in Denmark, Sweden, and Norway, respectively. Resurfacing of hips accounted for 0.5% or less in all countries. The posterior approach was used in 91% of cases in Denmark, 60% in Sweden, and 24% in Norway. Cemented THRs were used in 46% of patients in Denmark, in 89% of patients in Sweden, and in 79% of patients in Norway.
Of the 280,201 primary THRs, 9,596 (3.4%) had been revised. 10-year survival was 92% (95% CI: 91.6–92.4) in Denmark, 94% (95% CI: 93.6–94.1) in Sweden, and 93% (95% CI: 92.3–93.0) in Norway. In Denmark, 34% of the revisions were due to dislocation, as compared to 23% in Sweden and Norway. Replacement of only cup or liner constituted 44% of the revisions in Denmark, 29% in Sweden, and 33% in Norway.
Interpretation This unique common Nordic collaboration has shown differences between the countries concerning demographics, prosthesis fixation, and survival. The large number of patients in this database significantly widens our horizons for future research.
PMCID: PMC2823198  PMID: 19513887
4.  Herd and cow characteristics affecting the odds of veterinary treatment for disease – a multilevel analysis 
Research has indicated that a number of different factors affect whether an animal receives treatment or not when diseased. The aim of this paper was to evaluate if herd or individual animal characteristics influence whether cattle receives veterinary treatment for disease, and thereby also introduce misclassification in the disease recording system.
The data consisted mainly of disease events reported by farmers during 2004. We modelled odds of receiving veterinary treatment when diseased, using two-level logistic regression models for cows and young animals (calves and heifers), respectively. Model parameters were estimated using three procedures, because these procedures have been shown, under some conditions, to produce biased estimates for multi-level models with binary outcomes.
Cows located in herds mainly consisting of Swedish Holstein cows had higher odds for veterinary treatment than cows in herds mainly consisting of Swedish Red cows. Cows with a disease event early in lactation had higher odds for treatment than when the event occurred later in lactation. There were also higher odds for veterinary treatment of events for cows in January and April than in July and October. The odds for veterinary treatment of events in young animals were higher if the farmer appeared to be good at keeping records. Having a disease event at the same date as another animal increased the odds for veterinary treatment for all events in young animals, and for lameness, metabolic, udder and other disorders, but not for peripartum disorders, in cows. There were also differences in the odds for veterinary treatment between disease complexes, both for cows and young animals.
The random effect of herd was significant in both models and accounted for 40–44% of the variation in the cow model and 30–46% in the young animal model.
We conclude that cow and herd characteristics influence the odds for veterinary treatment and that this might bias the results from studies using data from the cattle disease database based on veterinary practice records.
PMCID: PMC2736961  PMID: 19698112
5.  Questionnaire-based study to assess the association between management practices and mastitis within tie-stall and free-stall dairy housing systems in Switzerland 
Prophylactic measures are key components of dairy herd mastitis control programs, but some are only relevant in specific housing systems. To assess the association between management practices and mastitis incidence, data collected in 2011 by a survey among 979 randomly selected Swiss dairy farms, and information from the regular test day recordings from 680 of these farms was analyzed.
The median incidence of farmer-reported clinical mastitis (ICM) was 11.6 (mean 14.7) cases per 100 cows per year. The median annual proportion of milk samples with a composite somatic cell count (PSCC) above 200,000 cells/ml was 16.1 (mean 17.3) %. A multivariable negative binomial regression model was fitted for each of the mastitis indicators for farms with tie-stall and free-stall housing systems separately to study the effect of other (than housing system) management practices on the ICM and PSCC events (above 200,000 cells/ml). The results differed substantially by housing system and outcome. In tie-stall systems, clinical mastitis incidence was mainly affected by region (mountainous production zone; incidence rate ratio (IRR) = 0.73), the dairy herd replacement system (1.27) and farmers age (0.81). The proportion of high SCC was mainly associated with dry cow udder controls (IRR = 0.67), clean bedding material at calving (IRR = 1.72), using total merit values to select bulls (IRR = 1.57) and body condition scoring (IRR = 0.74). In free-stall systems, the IRR for clinical mastitis was mainly associated with stall climate/temperature (IRR = 1.65), comfort mats as resting surface (IRR = 0.75) and when no feed analysis was carried out (IRR = 1.18). The proportion of high SSC was only associated with hand and arm cleaning after calving (IRR = 0.81) and beef producing value to select bulls (IRR = 0.66).
There were substantial differences in identified risk factors in the four models. Some of the factors were in agreement with the reported literature while others were not. This highlights the multifactorial nature of the disease and the differences in the risks for both mastitis manifestations. Attempting to understand these multifactorial associations for mastitis within larger management groups continues to play an important role in mastitis control programs.
PMCID: PMC3852534  PMID: 24107254
Cumulative incidence; Prevalence; Swiss dairy farms; Clinical mastitis; Subclinical mastitis; Prophylaxis; Management; Negative binomial regression; Somatic cell count
6.  Can pre-collected register data be used to identify dairy herds with good cattle welfare? 
Acta Veterinaria Scandinavica  2011;53(Suppl 1):S8.
Pre-recorded register data from dairy herds are available in almost all Nordic countries. These databases can be used for research purposes, and one of the research areas is animal welfare. The aim of this study was to investigate if pre-recorded register data could be used to identify herds with good welfare, and to investigate if a combination of register data sets could be used to be able to more correctly distinguish between herds with good welfare and herds with welfare deficiencies.
As a first step, nine animal-based measurements on calves, young stock and cows in 55 randomly selected herds were performed on-farm as the basis for a classification of welfare at the herd level. The definition for being a case herd with “good welfare” was no score lying among the 10% worst in any of the nine welfare measurements. Twenty-eight of the 55 herds were cases according to this definition. As a second step, 65 potential welfare indicators, based on register data in a national dairy database, were identified by expert opinion. In the final step, the extent to which the suggested welfare indicators predicted farms’ as having good welfare according to the stated definition was assessed. Moreover, the effect of combining in sequence a previously developed model that identified herds with poor welfare with the present model identifying herds with good welfare was investigated.
The final set of welfare indicators used to identify herds with good animal welfare included two fertility measures, cow mortality, stillbirth rate, mastitis incidence and incidence of feed-related diseases (including gastrointestinal disturbances but excluding paralyses and cramps). This set had a test sensitivity of correctly classifying herds with no score lying among the 10% worst of the nine welfare measurements of 96 %. However, the specificity of the test was only 56% indicating difficulties for the test to correctly classifying herds with one or more scores lying among the 10% worst. Combining the previously developed model with the present model, improved the welfare classification.
This study shows that pre-collected register data may be used to give approval to dairy farms with “good welfare” and that combining different sets of register data can improve the classification of herd welfare.
PMCID: PMC3194127  PMID: 21999569
7.  Managerial and environmental determinants of clinical mastitis in Danish dairy herds 
Several management and environmental factors are known as contributory causes of clinical mastitis in dairy herd. The study objectives were to describe the structure of herd-specific mastitis management and environmental factors and to assess the relevance of these herd-specific indicators to mastitis incidence rate.
Disease reports from the Danish Cattle Data Base and a management questionnaire from 2,146 herds in three Danish regions were analyzed to identify and characterize risk factors of clinical mastitis. A total of 94 (18 continuous and 76 discrete) management and production variables were screened in separate bivariate regression models. Variables associated with mastitis incidence rate at a p-value < 0.10 were examined with a factor analysis to assess the construct of data. Separately, a multivariable regression model was used to estimate the association of management variables with herd mastitis rate.
Three latent factors (quality of labor, region of Denmark and claw trimming, and quality of outdoor holding area) were identified from 14 variables. Daily milk production per cow, claw disease, quality of labor and region of Denmark were found to be significantly associated with mastitis incidence rate. A common multiple regression analysis with backward and forward selection procedures indicated there were 9 herd-specific risk factors.
Though risk factors ascertained by farmer-completed surveys explained a small percentage of the among-herd variability in crude herd-specific mastitis rates, the study suggested that farmer attitudes toward mastitis and lameness treatment were important determinants for mastitis incidence rate. Our factor analysis identified one significant latent factor, which was related to labor quality on the farm.
PMCID: PMC2268923  PMID: 18257917
8.  The association between farmers’ participation in herd health programmes and their behaviour concerning treatment of mild clinical mastitis 
In Denmark, it has recently become mandatory for all dairy farmers with more than 100 cows to sign up for a herd health programme. Three herd health programmes are available. These differ in a number of aspects, including the frequency of veterinary visits and the farmer’s access to prescription drugs. The objective of this study was to investigate whether dairy farmers’ behavioural intentions, i.e. to call a veterinarian or start medical treatment on the day that they detect a cow with mild clinical mastitis (MCM), are different depending on the type of herd health programme.
A questionnaire survey based on the Theory of Planned Behaviour (TPB) was conducted. TPB proposes that a person’s behavioural intention is strongly correlated with his or her actual behaviour. Three behavioural factors determine the behavioural intention: attitude, subjective norm and perceived behavioural control. Each of these factors is decided by a set of beliefs, each of which in turn is weighted by an evaluation: 1) the expected outcomes of performing the behaviour, 2) what a person believes that others think of the behaviour, and 3) the person’s perceived power to influence the behaviour.
A set of statements about the treatment of MCM based on interviews with 38 dairy farmers were identified initially. The statements were rephrased as questions and the resulting questionnaire was distributed to 400 randomly selected Danish dairy farmers who use the two most restrictive herd health programmes, either Core or Module1, and to all 669 farmers with the least restrictive herd health programme, Module2. The association between intention and the herd health programme was modelled using logistic regression.
The farmers with the Module2 herd health programme had a significantly higher behavioural intention to perform the behaviour, when compared to farmers with a more restrictive herd health programme (OR = 2.1, p < 0.0001).
Danish dairy farmers who participate in Module2 herd health programme had a higher intention to treat cases of MCM, compared to farmers who participate in a more restrictive herd health programme in which the veterinarian initiates treatments.
PMCID: PMC3537572  PMID: 23122271
Farmer behaviour; Theory of Planned Behaviour; Mild clinical mastitis; Herd health programme
9.  Euthanasia of Danish dairy cows evaluated in two questionnaire surveys 
Mortality risk in Danish dairy cows has more than doubled since 1990 (from 2% in 1990 to 5% in 2005). Until now, registrations about dead cows in the Danish Cattle Database have not included information about whether the cow died unassisted or was euthanized.
We interviewed a random sample of 196 Danish dairy farmers that had reported a dead cow to the Danish Cattle Database in 2002 and 196 dairy farmers that had reported a dead cow in 2006. Our objectives were to evaluate the proportion of euthanized cows, changes in the behaviour of farmers regarding euthanasia of cows over the years and possible reasons for these changes.
It seems that the threshold for euthanasia of cows among farmers has changed. Farmers generally reported a lower threshold for euthanasia compared to 5–10 years ago.
The threshold for euthanasia of cows has, according to the dairy farmers, become lower. This might have positive impacts on animal welfare as more seriously ill cows are euthanized in the herds and not put through a period of suffering associated with disease and treatment or transported to a slaughterhouse in poor condition.
PMCID: PMC2531113  PMID: 18718005
10.  Housing system and herd size interactions in Norwegian dairy herds; associations with performance and disease incidence 
According to the Norwegian animal welfare regulations, it has been forbidden to build new tie-stall barns since the end of 2004. Previous studies have shown that cow performance and health differ between housing systems. The interaction between housing system and herd size with respect to performance and disease incidence has not been evaluated.
Cow performance and health in 620 herds housed in free-stall barns were compared with in 192 herds housed in tie-stall barns based on a mail survey and data from the Norwegian Dairy Herd Recording and Cattle Health Systems. The housing systems herds were comparable with respect to herd size (15-55 cows). Associations between performance/disease incidence and housing system, herd size and year of building the cow barn were tested in general linear models, and values for fixed herd size of 20 and 50 cows were calculated. On the individual cow level mixed models were run to test the effect of among others housing system and herd size on test-day milk yield, and to evaluate lactation curves in different parities. All cows were of the Norwegian Red Breed.
Average milk production per cow-year was 134 kg lower in free-stall herd than in tie-stall herds, but in the range 27-45 cows there was no significant difference in yields between the herd categories. In herds with less than 27 cows there were increasingly lower yields in free-stalls, particularly in first parity, whereas the yields were increasingly higher in free-stalls with more than 45 cows.
In free-stalls fertility was better, calving interval shorter, and the incidence rate of teat injuries, ketosis, indigestions, anoestrus and cystic ovaries was lower than in tie-stalls. All of these factors were more favourable in estimated 50-cow herds as compared to 20-cow herds. In the larger herd category, bulk milk somatic cell counts were higher, and the incidence rate of mastitis (all cases) and all diseases was lower.
This study has shown that there is an interaction between housing system and herd size, and that performance and health is not universally better in small free-stalls than in tie-stalls.
PMCID: PMC2833153  PMID: 20158884
11.  Cross-sectional prospective survey to study indication-based usage of antimicrobials in animals: Results of use in cattle 
Indication-based data on the use of antimicrobials in animals were collected using a prospective cross-sectional survey, similarly as for surveys carried out in human medicine, but adapting the questionnaire to include veterinary-specific issues. The participating veterinarians were randomly selected from a sample population of practising veterinarians. The sampling was stratified to take into account the proportions of different types of veterinary practice in the country. All patients consulting the veterinary practice during a 1-week period were included in the study and veterinarians returned a completed questionnaire for each patient receiving antimicrobial treatment. As cattle received most of the treatments, results from the survey are given using cattle as an example species.
The survey was sent to 681 veterinarians, of whom 262 (39%) responded. In total 2850 questionnaires were completed. The largest quantities of antimicrobials, measured in kilograms, were used for cattle, followed by pigs, dogs and horses. The species that were treated most were cattle (n = 1308), dogs (n = 989) and cats (n = 311). For cattle, the most common reason for treatment was acute mastitis (52%), followed by dry-cow therapy (21%), subclinical mastitis (6%) and treatment for acute enteritis (4%). The remaining treatments covered 17% of cattle patients and 15 different indications. For acute mastitis, parenteral or intramammary treatment was used in 36% and 34% of the cases, respectively. The remaining 30% received both treatments simultaneously. Of the parenteral treatments (n = 459), benzyl penicillin was used in 83% of the treated animals (n = 379), while fluoroquinolones were used in 49 cases (11%). Of the 433 cows receiving intramammary treatment, ampicillin combined with cloxacillin was most commonly used (n = 157; 36%), followed by cephalexin+streptomycin (n = 113; 26%).
This cross-sectional prospective survey provided a useful method for the collection of information on the indication-based use of antimicrobials in different animal species. Cattle were the most commonly treated animal species during the study period. The most common indication for antimicrobial use in cows was mastitis. Benzyl penicillin was the drug most frequently used for the treatment of mastitis, which seems appropriate according to the national guidelines on the use of antimicrobials in cattle in Finland.
PMCID: PMC2375862  PMID: 18410674
12.  Insights into udder health and intramammary antibiotic usage on Irish dairy farms during 2003-2010 
Irish Veterinary Journal  2012;65(1):7.
By international standards, Ireland is a relatively small dairy producer. However, the industry plays a critical role to the national economy, accounting for approximately 3% of national gross domestic product. This paper presents insights into udder health and intramammary antibiotic usage on Irish dairy farms during 2003-2010, based on data from several sources. Three data sources were used, including data on milk recording data, intramammary antibiotic sales and animal health assessment. The milk recording data included a single unadjusted herd-level somatic cell count (SCC) value for each herd at each milk recording, being the arithmetic mean of cow-level SCC of each cow at that recording, weighted by cow-level yield. These data were used to calculate the percentage of herds each month where the unadjusted herd SCC exceeded 200,000 and 400,000 cells/mL. Two logistic generalised estimating-equations (GEE) models were developed, the outcome variable being either the probability that the monthly SCC of a herd was greater than 400,000 cells/mL or less than or equal to 200,000 cells/mL. Spring herds had a lower probability of a high SCC (> 400,000 cells/mL) during February to October compared to non-Spring herds but a higher probability between November to January. The odds of a high SCC were greater in 2005, 2006, 2009 and 2010 but less in 2007 and 2008 compared to 2004. Smaller herds had higher odds of having a high SCC compared to larger herds. We present the number of intramammary tubes and the quantity of active substance (kg) sold annually in Ireland during 2003-2010. We infer an incidence of clinical mastitis of 54.0 cases per 100 cow-years at risk, assuming 4 tubes per treatment regime, one affected quarter per cow, tubes restricted to clinical cases only and 100% of treated cases considered new cases, based on data collected on sales of in-lactation intra-mammary antibiotics. With differing assumptions, this estimate varied between 25.8 and 77.0 cases per 100 cow-years at risk. Using data on sales of dry cow therapy intra-mammary antibiotics, we also infer that most Irish dairy farmers use blanket dry cow therapy. It is important that Ireland has an objective understanding of current levels of udder health, to facilitate benchmarking and improvement into the future. Udder health is a concern on a number of Irish dairy farms. High SCC results were present throughout the year, but more marked towards the start and end of each milking season. Animal Health Ireland recently commenced a major national programme, CellCheck, in collaboration with a broad range of stakeholders, to support national SCC improvement. In this paper, relevant European and national legislation is also reviewed.
PMCID: PMC3376034  PMID: 22455802
13.  Mastitis and related management factors in certified organic dairy herds in Sweden 
Mastitis is one of the major threats to animal health, in organic farming as well as conventional. Preliminary studies of organic dairy herds have indicated better udder health in such herds, as compared to conventional herds. The aim of this paper was to further study mastitis and management related factors in certified organic dairy herds.
An observational study of 26 certified organic dairy herds in mid-eastern Sweden was conducted during one year. A large-animal practitioner visited the herds three times and clinically examined and sampled cows, and collected information about general health and management routines. Data on milk production and disorders treated by a veterinarian in the 26 herds, as well as in 1102 conventional herds, were retrieved from official records. Multivariable logistic regression was used to assess associations between herd type (organic vs. conventional) and incidence of disorders.
The organic herds that took part in the study ranged in size from 12 to 64 cows, in milk production from 3772 to 10334 kg per cow and year, and in bulk milk somatic cell counts from 83000 to 280000 cells/ml. The organic herds were found to have a lower incidence of clinical mastitis, teat injuries, and a lower proportion of cows with a high somatic cell count (as indicated by the UDS, Udder Disease Score) compared to conventional herds. The spectrum of udder pathogenic bacteria was similar to that found in other Swedish studies. Treatment of mastitis was found to be similar to what is practised in conventional herds. Homeopathic remedies were not widely used in the treatment of clinical mastitis.
The calves in most of these organic herds suckled their dams for only a few days, which were not considered to substantially affect the udder health. The main management factor that was different from conventional herds was the feeding strategy, where organic herds used a larger share of forage.
Udder health in Swedish organic herds appears to be better than in conventional herds of comparable size and production. The major difference in management between the two types of farms is the proportion of concentrates fed. The mechanisms explaining the association between intensity of feeding and udder health in dairy cows require further research.
PMCID: PMC1553465  PMID: 16987390
14.  Epidemiology of Kaposi's sarcoma in the Nordic countries before the AIDS epidemic. 
British Journal of Cancer  1996;74(9):1499-1502.
Based on data from the Nordic cancer registries, time-related trends in incidence of Kaposi's sarcoma (KS) were analysed in four ethnically similar populations before the AIDS epidemic. Data were available for different time periods in Denmark (1970-79), Sweden (1958-79), Finland (1953-79) and Norway (1953-79). KS was more common among men than among women aged 60 years or more, whereas no differences were observed for younger persons. The incidence of KS differed significantly between the four countries (P = 0.0001); Sweden having the highest and Denmark the lowest rates. Similarly, regional differences in incidence were observed within Sweden, rates being higher in the northern than in the southern areas (Ptrend = 0.002). Overall, in Nordic men the world standardised incidence rose from 0.5/1,000,000 person-years in the period 1953-57 to 1.8/1,000,000 person-years in 1978-79; in Nordic women, the corresponding rates were 0.2/1,000,000 person-years and 0.8/1,000,000 person-years respectively. The rate of increase was similar in Sweden, Finland and Norway (P = 0.14), whereas the short period of observation in Denmark precluded precise assessment of time-related incidence trends. These observations cannot be explained by registrational procedures or known risk factors for KS, and argue that environmental factors play an important role in the development of the disease.
PMCID: PMC2074794  PMID: 8912552
15.  Norwegian mastitis control programme 
Irish Veterinary Journal  2009;62(Suppl 4):S26-S33.
This paper describes the methods and results of the Norwegian Mastitis Control Program implemented in 1982. The program has formed an integral part of the Norwegian Cattle Health Services (NCHS) since 1995. The NCHS also have specific programs for milk fever, ketosis, reproduction and calf diseases. The goal of the program is to improve udder health by keeping the bulk milk somatic cell count (BMSCC) low, to reduce the use of antibiotics, to keep the cost of mastitis low at herd level and improve the consumers' attitude to milk products. In 1996, a decision was made to reduce the use of antibiotics in all animal production enterprises in Norway by 25% within five years. Relevant data has been collected through the Norwegian Cattle Herd Recording System (NCHRS); including health records since 1975 and somatic cell count (SCC) data since 1980. These data have been integrated within the NCHRS. Since 2000, mastitis laboratory data have also been included in the NCHRS. Data on clinical disease, SCC and mastitis bacteriology have been presented to farmers and advisors in monthly health periodicals since 1996, and on the internet since 2005. In 1996, Norwegian recommendations on the treatment of mastitis were implemented. Optimal milking protocols and milking machine function have been emphasised and less emphasis has been placed on dry cow therapy. A selective dry cow therapy program (SDCTP) was implemented in 2006, and is still being implemented in new areas. Research demonstrates that the rate of clinical mastitis could be reduced by 15% after implementing SDCTP. The results so far show a 60% reduction in the clinical treatment of mastitis between 1994 and 2007, a reduction in BMSCC from 250,000 cells/ml to 114,000 cells/ml, and a total reduction in the mastitis cost from 0.23 NOK to 0.13 NOK per litre of milk delivered to the processors, corresponding to a fall from 9.2% to 1.7% of the milk price, respectively. This reduction is attributed to changes in attitude and breeding, eradicating bovine virus diarrhoea virus (BVDV) and a better implementation of mastitis prevention programmes.
PMCID: PMC3339347  PMID: 22081877
breeding; BVDV; dry cow therapy; environment; mastitis; teat dipping
16.  Homogeneous Prostate Cancer Mortality in the Nordic Countries Over Four Decades 
European urology  2010;58(3):427-432.
Incidence of prostate cancer (PCa) has greatly increased in the Nordic region over the past two decades, following the advent of prostate-specific antigen (PSA) screening. Consequently, interpreting temporal trends in PCa has become difficult, and the impact of changes in exposure to causal factors is uncertain.
To reveal geographic differences and temporal trends in PCa in the Nordic countries. Because the recorded incidence of PCa has been profoundly influenced by PSA screening, we focused our analyses primarily on PCa mortality.
Design, setting, and participants
We analyzed national PCa incidence and mortality data from Denmark, Finland, Norway, and Sweden from 1965 to 2006 using the PC-NORDCAN software program and the online NORDCAN database.
Cumulative incidence and cumulative mortality from PCa were calculated for selected calendar years during four decades, along with age-standardized mortality rates. Incidence data in NORDCAN come from individual countries’ cancer registries, and mortality data come from national mortality registries.
Results and limitations
From 1965 to 2006, 172 613 deaths from PCa were reported in the four Nordic countries. A substantial rise in incidence was observed across the region, with some geographic variation, since the late 1980s. In contrast, both disease-specific mortality rates and cumulative risk of PCa mortality lacked consistent temporal trends over the same period. Cumulative risk of PCa mortality ranged between 3.5% and 7.5% in the region over four decades, whereas cumulative incidence jumped from about 9% to >20%. Mortality has remained fairly constant among the countries, with a minimally lower risk in Finland.
Unlike most malignancies, the occurrence of lethal PCa showed minimal geographic variation and lacked consistent temporal trends over four decades. These findings may guide our search for important causes of PCa, a malignancy with etiology that is still largely unknown.
PMCID: PMC2936655  PMID: 20541313
Cancer trends; Mortality; Nordic region; Prostate cancer
17.  Plasma Vitamin E and Blood Selenium Concentrations in Norwegian Dairy Cows: Regional Differences and Relations to Feeding and Health 
Acta Veterinaria Scandinavica  2005;46(4):177-191.
Plasma α-tocopherol (vit E) and blood selenium (Se) concentrations in February were determined in samples from 314 dairy cows in Norway, selected to provide a representative subset of the Norwegian dairy cow population. Each sample was followed by a questionnaire with information about feeding of the cow at the time of sampling. The results were correlated to herd data and to calving and health data for each cow from the Norwegian Dairy Herd Recording System and the Norwegian Cattle Health Recording System. The mean concentrations were 6.9 μg vit E per ml plasma and 0.16 μg Se per g blood. Both levels were highest in mid lactation. Plasma vit E varied with the amount of silage fed to the cow, while blood Se varied with the amount of concentrates and mineral supplements, and with geographical region. No differences in vit E or Se levels were found between cows with recorded treatments for mastitis, parturient paresis or reproductive disorders in the lactation during or immediately prior to sampling, and those without such treatments. For ketosis, a small difference in blood Se was found between the groups with or without recorded treatments. It is concluded that winter-fed lactating cows in Norway had an adequate plasma level of vit E and a marginal-to-adequate level of Se.
PMCID: PMC1618972  PMID: 16398330
Vitamin E; selenium; dairy cows; feeding; health; mastitis; reproduction; Norway
18.  Countrywise results of total hip replacement 
Acta Orthopaedica  2014;85(2):107-116.
Background and purpose
An earlier Nordic Arthroplasty Register Association (NARA) report on 280,201 total hip replacements (THRs) based on data from 1995–2006, from Sweden, Norway, and Denmark, was published in 2009. The present study assessed THR survival according to country, based on the NARA database with the Finnish data included.
Material and methods
438,733 THRs performed during the period 1995–2011 in Sweden, Denmark, Norway, and Finland were included. Kaplan-Meier survival analysis was used to calculate survival probabilities with 95% confidence interval (CI). Cox multiple regression, with adjustment for age, sex, and diagnosis, was used to analyze implant survival with revision for any reason as endpoint.
The 15-year survival, with any revision as an endpoint, for all THRs was 86% (CI: 85.7–86.9) in Denmark, 88% (CI: 87.6–88.3) in Sweden, 87% (CI: 86.4–87.4) in Norway, and 84% (CI: 82.9–84.1) in Finland. Revision risk for all THRs was less in Sweden than in the 3 other countries during the first 5 years. However, revision risk for uncemented THR was less in Denmark than in Sweden during the sixth (HR = 0.53, CI: 0.34–0.82), seventh (HR = 0.60, CI: 0.37–0.97), and ninth (HR = 0.59, CI: 0.36–0.98) year of follow-up.
The differences in THR survival rates were considerable, with inferior results in Finland. Brand-level comparison of THRs in Nordic countries will be required.
PMCID: PMC3967250  PMID: 24650019
19.  Are health inequalities really not the smallest in the Nordic welfare states? A comparison of mortality inequality in 37 countries 
Research comparing mortality by socioeconomic status has found that inequalities are not the smallest in the Nordic countries. This is in contrast to expectations given these countries’ policy focus on equity. An alternative way of studying inequality has been little used to compare inequalities across welfare states and may yield a different conclusion.
We used average life expectancy lost per death as a measure of total inequality in mortality derived from death rates from the Human Mortality Database for 37 countries in 2006 that we grouped by welfare state type. We constructed a theoretical ‘lowest mortality comparator country’ to study, by age, why countries were not achieving the smallest inequality and the highest life expectancy. We also studied life expectancy as there is an important correlation between it and inequality.
On average, Nordic countries had the highest life expectancy and smallest inequalities for men but not women. For both men and women, Nordic countries had particularly low younger age mortality contributing to smaller inequality and higher life expectancy. Although older age mortality in the Nordic countries is not the smallest. There was variation within Nordic countries with Sweden, Iceland and Norway having higher life expectancy and smaller inequalities than Denmark and Finland (for men).
Our analysis suggests that the Nordic countries do have the smallest inequalities in mortality for men and for younger age groups. However, this is not the case for women. Reducing premature mortality among older age groups would increase life expectancy and reduce inequality further in Nordic countries.
PMCID: PMC3607094  PMID: 23386671
Inequalities; Mortality; Demography
20.  Knee arthroplasty in Denmark, Norway and Sweden 
Acta Orthopaedica  2010;81(1):82-89.
Background and purpose
The number of national arthroplasty registries is increasing. However, the methods of registration, classification, and analysis often differ.
We combined data from 3 Nordic knee arthroplasty registers, comparing demographics, methods, and overall results. Primary arthroplasties during the period 1997–2007 were included. Each register produced a dataset of predefined variables, after which the data were combined and descriptive and survival statistics produced.
The incidence of knee arthroplasty increased in all 3 countries, but most in Denmark. Norway had the lowest number of procedures per hospital—less than half that of Sweden and Denmark. The preference for implant brands varied and only 3 total brands and 1 unicompartmental brand were common in all 3 countries. Use of patellar button for total knee arthroplasty was popular in Denmark (76%) but not in Norway (11%) or Sweden (14%). Uncemented or hybrid fixation of components was also more frequent in Denmark (22%) than in Norway (14%) and Sweden (2%).
After total knee arthroplasty for osteoarthritis, the cumulative revision rate (CRR) was lowest in Sweden, with Denmark and Norway having a relative risk (RR) of 1.4 (95% CI: 1.3–1.6) and 1.6 (CI: 1.4–1.7) times higher. The result was similar when only including brands used in more than 200 cases in all 3 countries (AGC, Duracon, and NexGen). After unicompartmental arthroplasty for osteoarthritis, the CRR for all models was also lowest in Sweden, with Denmark and Norway having RRs of 1.7 (CI: 1.4–2.0) and 1.5 (CI: 1.3–1.8), respectively. When only the Oxford implant was analyzed, however, the CRRs were similar and the RRs were 1.2 (CI: 0.9–1.7) and 1.3 (CI: 1.0–1.7).
We found considerable differences between the 3 countries, with Sweden having a lower revision rate than Denmark and Norway. Further classification and standardization work is needed to permit more elaborate studies.
PMCID: PMC2856209  PMID: 20180723
21.  A descriptive epidemiological study of mastitis in 12 Irish dairy herds 
Irish Veterinary Journal  2005;58(1):31-35.
Factors relating to the occurrence of mastitis were studied on 12 Irish dairy herds with histories of elevated somatic cell count (SCC) and/or increased incidence of clinical mastitis cases. Milk recording data were analysed, housing conditions and calving areas were examined; dry cow therapy, clinical mastitis records, milking technique and aspects of milking machine function were assessed.
Herds with a ratio of less than 110 cubicles per 100 cows were more likely to experience environmental mastitis. Herds with inadequate calving facilities, where cows spent prolonged periods on straw bedding, were likely to acquire environmental mastitis. In the majority of the herds, the selection of dry cow therapy lacked adequate planning. The majority of farmers took no action to reduce pain experienced by cows suffering mastitis. Deficiencies in parlour hygiene were evident in all herds experiencing elevation in SCC.
PMCID: PMC3113918  PMID: 21851663
Cattle; Cows; Mastitis; Milking routine; Cow housing; Dry cow therapy
22.  Trends in cow numbers and culling rate in the Irish cattle population, 2003 to 2006 
Irish Veterinary Journal  2008;61(7):455-463.
Cows are the main economic production units of Ireland's cattle industry. Therefore, demographic information, including overall numbers and survival rates, are relevant to the Irish agricultural industry. However, few data are available on the demographics of cows within a national population, either in Ireland or elsewhere, despite the recent development of comprehensive national cattle databases in many EU Member States. This study has sought: to determine the rate of cow culling from the national herd; to determine the rate of culling by type (dairy, beef), age, method of exit, date of exit and interval between last calving and exit; to calculate the national cow on-farm mortality rate; and to compare the Irish rates with published data from other countries. This work was conducted using data recorded in the national Cattle Movement Monitoring System (CMMS). Culling refers to the exit of cows from the national herd, as a result of death but regardless of reason, and cow-culling rate was calculated as the number of cow exits (as defined above) each year divided by the number of calf births in the same year. Culling rate was determined by type (dairy or beef), date of birth, method of exit (slaughter or on-farm death), month of exit and interval between last calving and exit. The average cow-culling rate during 2003 to 2006 was 19.6% (21.3% for dairy, 18% for beef). While comparisons must be treated with caution, it concluded that the overall rates of culling in Ireland fell within published internationally accepted norms. The on-farm mortality rate of 3.2-4.1% was similar to that reported in comparable studies.
PMCID: PMC3113867  PMID: 21851717
abattoir slaughter; CMMS; cull cow; national herd turnover rate; on-farm-death; population balance
23.  Factors Associated with Mastitis in Ontario Dairy Herds: A Case Control Study 
Data from Ontario dairy cattle herds which had had a high average milk gel index for 1978 (cases) and from other herds which had had a low average during the same period (controls) were collected and analyzed using case control techniques. The purpose of the study was to contrast factors of husbandry and management between the two groups and to determine the relative contribution of each of these factors on mastitis (as determined indirectly by the milk gel index) at the herd level.
Control herds had higher average production levels than did case herds, shipping 1807 litres more milk per cow per year. Milk from control herds averaged 0.06 percentage points higher in butterfat, 0.19 percentage points higher in lactose and 0.05 percentage points lower in total protein. However, many factors can influence production, therefore these latter differences, in both shipped milk and composition, can not be attributed solely to differences in the prevalence of mastitis between the two groups.
Control herds were more likely to use teat dip, receive regular veterinary service, use dry cow antibiotic preparations and have knowledge concerning subclinical mastitis than were case herds. Control herds also tended to raise more of their own replacements, have a higher culling rate for reasons of low production and have a more modernized dairy operation. Case herds, on the other hand, were more likely to scrutinize foremilk, use more milking units per operator and wait longer between the start of stimulation and attachment of the milking unit.
The study confirms, under natural field conditions, the importance of integrated mastitis control practices and also reaffirms the relative importance of practices such as the use of teat dips and dry cow antibiotic preparations.
PMCID: PMC1320089  PMID: 7448625
24.  Health inequalities by education and age in four Nordic countries, 1986 and 1994 
Study objective: To compare the age pattern of educational health inequalities in four Nordic countries in the mid-1980s and the mid-1990s.
Design: Cross sectional interview surveys at two points of time.
Setting: Data on self reported limiting longstanding illness, and perceived health were collected from Denmark, Finland, Norway, and Sweden in 1986/87 and in 1994/95.
Participants: Representative samples of the non-institutionalised population at 15 years or older. Analyses were restricted to respondents aged between 25 and 75 (n= 23 325 men and 24 184 women). Response rates varied from 73% to 87%.
Main results: The age adjusted prevalence of limiting longstanding illness in Finland was 10% higher in men and 6% higher in women than in other Nordic countries in 1986/87 but the gap narrowed by 1994/95. Educational health inequalities were largest in Norway. In 1986/87 the odds ratio (OR) for limiting longstanding illness was 11.25 (95% CI 8.66 to 14.62) among men and 8.23 (95% CI 6.60 to 10.27) among women in the oldest age group (65–74 years old) in Finland when the youngest age group (25–34 years old) was used as the reference category (OR=1.00). The age pattern in Finland was steeper than in Sweden (OR=5.02, 95% CI 3.97 to 6.34 in men and 5.29, 95% CI 4.18 to 6.71 in women) or Norway (OR=6.32, 95% CI 4.06 to 9.84 and 5.45, 95% CI 3.81 to 7.82, respectively). In 1994/95 relative health improved in the oldest age group in Finland (OR=5.80, 95% CI 4.33 to 7.78 in men and 5.94, 95% CI 4.52 to 7.79 in women) and in Norway (OR=4.55, 95% CI 3.01 to 6.88 and 3.96, 95% CI 2.70 to 5.81, respectively) but remained stable in Sweden. The study compared health differences by age in different educational categories and found that in Finland in 1986/87 the health in the oldest age group was poorer for secondary (OR=10.59, 95% CI 5.96 to 18.82) or basic educated (OR=9.76, 95% CI 6.66 to 14.30) men than for men with higher education (OR=5.15, 95% CI 2.59 to 10.22). The difference was not found among women or in other Nordic countries and it diminished among men in Finland in 1994/95. The results of perceived health were broadly similar to the above results of limiting longstanding illness.
Conclusion: The results suggest that compared with other Nordic countries the comparatively poorer health in Finland is partly attributable to a cohort effect. This may be associated with the lower standard of living in Finland that lasted until the mid-1950s. The cohort effect is also likely to contribute to educational health inequalities among older Finnish men. The results suggest that not only current social policies but also past economic circumstances are likely to affect the overall health status as well as health inequalities.
PMCID: PMC1732117  PMID: 11896131
25.  The Nordic Patient Experiences Questionnaire (NORPEQ): cross-national comparison of data quality, internal consistency and validity in four Nordic countries 
BMJ Open  2012;2(3):e000864.
To evaluate the Nordic Patient Experiences Questionnaire (NORPEQ) for data quality, reliability and validity following surveys of patients in Finland, Norway, Sweden and the Faroe Islands.
Design, methods and participants
The NORPEQ was mailed to 500 patients randomly selected after receiving inpatient treatment in Finland, Norway and Sweden. The NORPEQ was also included in a national survey in Norway and in the Faroe Islands. Dimensionality was assessed using principal component analysis and internal consistency by item-total correlation and Cronbach's α. Construct validity was assessed by correlating NORPEQ scores with variables known to be related to patient experiences.
Somatic hospitals in Finland, Faroe Islands, Norway and Sweden.
Primary and secondary outcome measures
Item missing, internal consistency reliability and construct validity.
Response rates ranged from 45.8% in Norway to 84% for Sweden. Levels of missing data were low for all items across the surveys. Principal component analysis identified one component with six experiences items. Mean NORPEQ scores ranged from 74 to 79 on the 0–100 scale, where 100 represents the best possible experiences. Cronbach's α ranged from 0.84 in Finland to 0.88 in Sweden.
The NORPEQ is a brief measure of patient experiences that covers important aspects of the healthcare encounter. It shows good evidence of reliability and validity.
Practice implications
The NORPEQ instrument is recommended for cross-national comparisons of healthcare experiences for the four Nordic countries.
Article summary
Article focus
The NORPEQ was designed to include a core set of questions covering the most important aspects of patient experiences that can be used cross-nationally and alongside existing longer-form national survey questionnaires.
The aim of this study was to evaluate the psychometric properties of NORPEQ in four Nordic countries.
Key messages
On the basis of a rigorous process of questionnaire development and evaluation including forward–backwards translation, levels of missing data analysis, dimensionality, internal and construct validity, the NORPEQ shows good evidence of reliability and validity.
The NORPEQ instrument is recommended for cross-national comparisons of healthcare experiences in the Nordic countries.
Strengths and limitations of this study
The NORPEQ includes what are evaluated to be the most important aspects of experiences for patients. Levels of missing data were generally very low across countries indicating the acceptability of the questionnaire.
The NORPEQ was tested in four countries, and there is good evidence for the cross-cultural equivalence of the questionnaire.
Results were based on pilot surveys in two countries and should be further evaluated following national surveys. Psychometric properties of the NORPEQ should also be tested in Denmark and Iceland.
PMCID: PMC3367149  PMID: 22649175

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