Health risks, emergency preparedness and Norwegian-Russian cooperation on Svalbard. A systematic review

Figures & data

Table 1. Search words and search combinations

	Category 1: Search words related to «healthcare»	Category 2: Search words related to «emergency preparedness»:	Category 3: Search words related to «Svalbard»:
English	health	emergency preparedness	Svalbard
			Spitsbergen
	healthcare	crisis
	hospital	search and rescue
		disaster
		ambulance
Russian	здоровье	готовность к чрезвычайным ситуациям	Свaльбард
			Шпицберген
	здравоохранение	кризис
	больница	поисково-спасательные работы
		ЧП (чрезвычайное происшествие)
		скорая помощь
		санитарный вертолёт (in Russian, unlike English and Norwegian, the word for ambulance diverts completely from the term «air ambulance», hence two different terms to describe the different types of ambulances)
Norwegian	helse	beredskap	Svalbard
			Spitsbergen
	helsevesen	krise
	sykehus	søk og redning
		katastrofe
		ambulanse

Figure 1. Process figure.

Table 2. Casp evaluation table

GRADE categories
No.	Author	Title	Aim of study	Description	Key findings	Comments	Quality level
Category 1 – Diseases
1	Andersen et al., 1997	Occurrence of otitis media in an Arctic region	To investigate the occurrence of otitis media (OM – middle ear infection) and explore associations between OM and weather conditions on Svalbard	Patient information was extracted from the patient registry at Longyearbyen hospital and matched with weather data	202 patients with otitis media were registered in the study period (1991–1994) Peak (although minor) in the occurrence of otitis media in spring and autumn	Failure to adequately control the confounding, such as bacteriological causes No control group on the mainland No statistical analysis of the observed associations	Very low
7	Lilleng et al., 2008	Seasonal variation of migraine in an Arctic population	To investigate seasonal variation of migraine headache in a population residing in an extreme Arctic locale	A postal questionnaire was mailed to all Norwegian inhabitants aged 12 years or older living in Svalbard and the migraine diagnosis made by a structured telephone interview	Of the study participants (N = 1029), 184 experienced headache within the recent year prior to the study that could not be explained by alcohol, trauma, or viral infections. 88 individuals had migraine; 19 reported seasonal variation of migraine; 10 experienced more migraine in the light season, while 9 got worse in the dark season No indication of more seasonal variation of headache in a population of otherwise healthy people with migraine living in an extreme Arctic area with long periods of midnight sun and polar nights with complete darkness	Failure to adequately control the confounding, such as the effect of Svalbard residents who spend their summers in a warmer climate (i.e. on mainland Norway) Small sample Low response rate	Very low
9	Nilssen et al., 1999	Self-reported seasonal variation in depression at 78 degree north. The Svalbard Study	To explore and compare the one year prevalence of self-reported depression in two ethnically different populations	A cross-sectional study of Norwegians (N = 506) and Russians (N = 446) living on Svalbard	Among Russians, the one-year prevalence of self-reported depression lasting for at least 2 weeks was 26.8% for men and 44.7% for women Corresponding figures for the Norwegians were 10.7% and 15.6% As both populations were exposed to the same amount of daylight, seasonal depression is not solely a matter of lack of daylight	Failure to adequately control the confounding, such as different cultural conceptions of the term “depression” Challenging comparative element, as the data from the Norwegian population was collected four years before the data for the Russian population No information about the total population in the Russian settlement of Barentsburg (authors estimate that c. 30–40% participated in the study), implying a risk of selection bias Deviating quality on data material: Norwegian data: high adequacy Russian data: low adequacy	Data concerning the Russian population: low Data concerning the Norwegian population: moderate
Category 2 – Risk factors for diseases
2	Bojko, 1997	Metabolical changes induced by adaptation to circumpolar conditions in Spitsbergen	To search for hormonal and metabolical indices in humans living in extreme environmental conditions	Serum metabolic and hormonal parameters were examined four times per year in 577 healthy men on Svalbard	Serum creatinine and pyruvate reflected the tissue metabolism and were activated in cold time Serum urea and total T3 were associated with the metabolical transformation resulting from rapid changes in light conditions	Failure to adequately control the confounding, such as possible replacement among the study participants No information about the total population, implying a risk of selection bias Flawed study design, analyses of sequential group means instead of repeated measurements in individuals	Very low
3	Bojko and Larsen, 1999	Changes in the serum lipid profile in man during 24 months of Arctic residence	To examine the serum lipid profile in Caucasian miners on Svalbard (78–79 °N) from the south part of Ukraine and Russia (48 °N) in order to reveal possible effects of exposure time under High Arctic conditions	Study subjects (N = 99) were divided into five groups according to their time of residence (1, 3, 6, 12 and 24 months) on Svalbard and blood samples collected	The results indicate a rise of triglyceride levels after about 12 months stay Elevated levels of 18:3 and 16:1 fatty acids imply dietary modifications of the serum fatty acids	Failure to adequately control the confounding, such as changed diet No control group on the mainland Did not describe eligibility criteria No information about the underlying total population, implying a risk of selection bias.	Very low
18	Breus et al., 2015	Magnetic storms and variations in hormone levels among residents of North Polar area – Svalbard	The aim of this study was to find the possible sensitivity of these biochemical parameters to variations of external natural factors at high latitudes in three independent groups of people living in this region.	Hormone levels were analysed from blood samples of three groups of people living in Barentsburg (N = 364 + 274 + 280 (918)) in four different seasons (spring, summer, autumn, winter) in 1991–1992, and analysed against parameters for geomagnetic activity.	The study shows for the first time that at high geographical latitudes with increased level of GMA (geomagnetic activity) a significant change in the level of secretion of several hormones leads to an adaptive stress reaction.	Failure to adequately control confounding, such as connection between geomagnetic activity and weather. The authors do not consider Barentsburg’s selected and healthy population, nor natural seasonal variations. Small core sampling group (only 27 people were able to be investigated in all four seasons).	Very low
4	Forberg et al., 2010	Subjective and objective sleep and sleepiness among tunnel workers in an extreme and isolated environment: 10-h shifts, 21-day working period, at 78 degrees north	To examine the effects of extended work hours (10 h on, 14 h off for 21 days) on sleep and sleepiness in an extreme and isolated environment in the far north (Svalbard, 78 degrees north)	The work consisted of tunnel construction in Svea, Svalbard. The participants (25 male workers, aged 24–60 years) worked an alternate fixed day shift (06:00–16:00) or a fixed night shift (18:00–04:00) for a 21-day work period in a counterbalanced, crossover design. Subjective and objective measures of sleep (diary and actigraphy), as well as a subjective daytime sleepiness and function questionnaire, were applied	There were few differences between the day and night shift periods and across the 21-day working period	Failure to adequately control the confounding, such as the healthy worker effect, limits external validity High internal validity Few participants	Low
5	Hanoa et al., 2011	No difference in self-reported health among coalminers in two different shift schedules at Spitsbergen, Norway, a two years follow-up	To investigate possible changes in health after a voluntary implementation of a new shift schedule, with periods of 14 d on and 14 d off	A questionnaire was distributed to all employees before and two times after the new shift schedule, comprising questions on type of work, shift schedule, pain, sleep, stress, and coping	Work neither in the 14/14 shift nor 7/7 shift was related to any change in the health after two years	Failure to adequately control the confounding, such as the motivation among the participants to choose a particular shift regime, limits external validity High internal validity	Low
6	Høyer et al., 1996	The Svalbard Study 1988–89: a unique setting for validation of self-reported alcohol consumption	To investigate to what degree people answer truthfully when self-reporting alcohol consumption. Because of the unique situation applying to Svalbard in terms of alcohol sales and distribution, the estimate made in this study was believed to be more reliable compared to other studies using sales volume to validate self-reports	Sales recorded from all agencies selling alcohol on Svalbard were recorded for a two-month period. During the same period all Norwegian adults living permanently on Svalbard were invited to take part in a health screening, including answering a questionnaire about alcohol consumption	513 respondents reported that 3284 alcohol units were consumed during the registration week, which corresponded to a mean annual consumption of pure alcohol of 6.25 litres per capita. Men and women reported a mean consumption of 8.01 and 3.03 litres respectively The study found that the self-reported volume of alcohol accounted for approximately 40% of the sales volume	Failure to adequately control for the confounding, such as export of alcohol to the mainland Moderate response rate (63%), implying a risk of selection bias Did not address potential comparative element – whether the consumption of alcohol was different from comparable populations on the mainland	Very low
12	Schirmer et al., 1991	The Svalbard Study: risk of coronary heart disease at 78 degrees north	To investigate the risk of coronary heart disease among adults living on Svalbard	All Norwegian persons aged 18 and over with intended stay on Svalbard for over three months were included. Of the 818 persons fulfiling the criteria, 612 (75%) participated. Data concerning risk factors for coronary heart disease was collected from two questionnaires, and a personal consultation in which blood pressure, pulse rate, height and weight and expiratory peak flow were measured, in addition to blood samples	The Svalbard population displays a coronary heart disease risk profile similar to that of the Norwegian population living on the mainland	Descriptive reporting of negative findings, few data documenting the findings provided No statistical analyses of data presented comparing the Svalbard and mainland populations	Low
14	Yenikeev et al., 2007	Investigating the impact of heliogeophysical activity on healthy people working in polar areas	To explore the effect of geomagnetic disturbances on human health	Satellite data and patient data from the hospital archives in the Russian settlement Barentsburg were recorded for the years 1985 through 2001. Temporal patterns of geomagnetic disturbances were compared with frequencies of hospital visits	564 health incidents were reported in between 1985 and 2001. Of these, 297 were traumas, and 267, cardiovascular disease Almost half of all reported health incidents coincided with periods of strong geomagnetic activity	Failure to adequately control the confounding, such as the correlation between geomagnetic activity and number of exposed persons, and the connection between geomagnetic activity and weather. Flawed study design as no statistical analyses of associations between geomagnetic activity and the frequency of diseases and injuries were performed	Very low
Category 3 – Traumatic injuries
10	Risholt, 1992	Accident toll in a Norwegian Spitsbergen mining community	To investigate the accident toll among the Norwegian population living on Svalbard between 1950 and 1989	Data was gathered from the Longyearbyen hospital archive and cross-checked against the register of the Norwegian mining company	Total loss of 84 persons in fatal accidents from 1950 to 1989 The Svalbard population run a risk of being involved in a fatal leisure-time accident nearly 3 times (males) and 18 (females) higher than that of comparable age groups on the Norwegian mainland Up until the 1970s the great majority of injuries causing deaths were related to mining Non-occupational fatal injuries have been on the rise since then	Failure to adequately control the confounding, e.g. no adjustment for age within wide age groups (20–59 years) Does not provide estimates of confidence, high risk of random variation in point estimates High accuracy in reporting traumas in the relevant time period	Low
11	Risholt et al., 1998	Man and polar bear in Svalbard: a solvable ecological conflict?	The objective of the study was twofold. First, to assess the nature and magnitude of the polar bear-human conflict with respect to injuries to man and bear. Second, a major concern has been to minimise injurious interactions in order to safeguard the people who live and work in the Arctic, and, at the same time, secure the future of the polar bear	Reports on serious interactions between humans and polar bears in the Svalbard area during the 25-year period from 1971 to 1995 were reviewed. Records were collected from the files of Sysselmannen, the Governor of Svalbard, and from the files of Longyearbyen Hospital	Approximately 80 bears were involved in serious interactions with humans. Of those, 77 were killed. 10 persons were injured, four fatally, on seven occasions	High accuracy and high internal validity	Moderate
15	Ytterstad and Norheim (1), 2001	Snowmobile injuries in Svalbard – a three-year study	To survey snowmobile injury events treated in Longyearbyen hospital, Svalbard, and to report the injury distribution and characteristics for Norwegian Svalbard residents and visitors driving snowmobiles	Injured people treated in the hospital emergency room in Longyearbyen were recorded prospectively from 8 March 1997 for three years	The injury rate for Norwegian residents was 17,4 per 1000 registered vehicles per year The injury rate for visitors was four times higher than resident rate Almost all accidents are leisure related	Uncertainty about injury rates for visitors, as the exact number of visitors was unknown Accuracy for Norwegian residents: high	Data concerning Norwegian residents: moderate Data concerning visitors: very low
16	Ytterstad and Norheim (2), 2001	The epidemiology of injuries in Svalbard compared with Harstad	To survey all injuries treated in Longyearbyen hospital, Svalbard, and to describe the injury epidemiology for Norwegian Svalbard residents and visitors, comparing it with Harstad	Injured people treated in the hospital emergency rooms in Longyearbyen and Harstad were recorded prospectively from 8 March 1997 for three years	The crude injury rate (per 100 person years) for Svalbard residents were for men 100.9 and for women 76.3 Corresponding rates were not significantly higher in Harstad (115.4 for men and 80.1 for women) Home injuries were more prevalent in Harstad (30.5%), compared to Svalbard residents (13.1%) and visitors (8.9%) Work- and leisure-related injuries were more prevalent for Svalbard visitors (38.8% and 48.7%) and residents (27.2% and 41.9%), compared to Harstad (13.2% and 34.8%) The violence (per 1000 person years) was 0.9 for Svalbard resident, less than a third of the Harstad rate	Failure to adequately control the confounding, such as differences in age distribution on Svalbard versus Harstad Uncertainty about injury rates for visitors, as the exact number of visitors was unknown The evidence for Svalbard residents is robust The comparative element with Harstad is weak, as the authors have not considered the differences in age distribution between Svalbard and Harstad	Data concerning Svalbard: moderate Comparative analysis: very low
17	Ytterstad and Dahlberg, 2005	Snowmobile injuries in Svalbard	To survey snowmobile injury events treated in Longyearbyen hospital, Svalbard, and to report the injury distribution and characteristics for Svalbard residents and visitors driving snowmobiles	Injured people treated in the hospital emergency room in Longyearbyen were recorded prospectively from 8 March 1997 for five years	181 snowmobile accidents were registered in the period The mean injury rate for Norwegian residents was 12,9 per 1000 person years The mean injury rate per 1000 snowmobiles per year was 18 for residents and 70 for visitors Nine of ten snowmobile injuries occurred during leisure time The mean age of injured visitors was ten years older than injured permanent residents	Uncertainty about injury rates for visitors, as the exact number of visitors was unknown Accuracy for Norwegian residents high	Data concerning Norwegian residents: moderate Data concerning visitors: very low
GRADE-CERQual categories
Number	Author	Title	Aim of study	Description	Key findings	Comments
Category 2 – Risk factors for diseases
8	Mehus et al., 2016	Young People and Snowmobiling in Northern Norway: accidents, injury prevention and safety strategies	To reveal how young people experience and interpret accidents, and to outline a prevention strategy	Thirty-one girl and 50 boys aged 16–23 years from secondary schools in Northern Norway and on Svalbard, participated in 17 focus groups divided by gender. A content analysis identified themes addressing the research questions	Adolescents are aware of how accidents occur and how to avoid them The participants described risk as a natural part of snowmobile driving and claimed that accidents happen because of poor risk assessment, careless driving, or mistakes	The scope of the article is to explore how young people in Northern Norway and Svalbard experience accidents and the article is thus not solely devoted to Svalbard. Approximately 10% of the respondents were from Svalbard. This implies concern about the study’s relevance for the young people on Svalbard
Category 4 – Search and rescue (SAR)
13	Tengesdal et al., 2017	A qualitative study of the role of the local population in Longyearbyen in the management of avalanches and avalanche drills [«Vi var fullstendig avhengig av hjelpen fra lokalbefolkningen» – En kvalitativ studie av rollen lokalbefolkningen i Longyearbyen har i håndteringen av snøskred og snøskredøvelse]	To explore the role of the local population in Longyearbyen during urban avalanches	Qualitative interviews with public and private SAR actors in Longyearbyen	The local population is a resource for SAR situations on Svalbard. SAR actors expect local population to contribute to SAR operations. The local population could be included in drills etc. more regularly	A solid study with reliable findings

Table 3. Evidence profile tables

GRADE Evidence Profile
Outcome	Studies contributing to the review finding	Study limitations	Inconsistency of results	Indirectness of evidence	Imprecision	Publication bias	Quality of the evidence
Diseases	1, 7, 9	Serious limitations	N/A	N/A	N/A	Undetected	Low
Risk factors for diseases	2–6, 12, 14, 18	Serious limitations	N/A	N/A	Serious imprecision	Undetected	Low to very low
Traumatic injuries	10–11, 15–17	Serious limitations	N/A	N/A	Serious imprecision	Undetected	Quality of evidence concerning Norwegian residents (15,17) on Svalbard (16): moderate Quality of evidence concerning visitors (15,17) and comparisons with the mainland population (16): very low
Search and rescue (SAR)	-	-	-	-	-	-	No evidence
Norwegian-Russian cooperation	-	-	-	-	-	-	No evidence
GRADE-CERQual Evidence Profile
Outcome	Studies contributing to the review finding	Methodological limitations	Coherence	Adequacy	Relevance	CERQual assessment of confidence in the evidence	Explanation of CERQual assessment
Diseases	-	-	-	-	-	-	No evidence
Risk factors for diseases	8	No concerns about methodological limitations	No concerns about coherence	No concerns about adequacy	Serious concerns about relevance	Very low confidence	Serious concerns regarding relevance reduces the confidence in the review findings. Only approximately 10% of the study participants were from the study area
Traumatic injuries	-	-	-	-	-	-	No evidence
Search and rescue (SAR)	13	No concerns about methodological limitations	No concerns about coherence	No concerns about adequacy	No concerns about relevance	High confidence	Solid study with reliable findings
Norwegian – Russian cooperation	-	-	-	-	-	-	No evidence

Table 4. Summary of findings tables

GRADE Summary of findings
Outcome	Summary of review finding	Studies contributing to the review finding	Quality of the evidence	Comments
Disease	No evidence of an increased risk for disease on Svalbard	1, 7, 9	Low	Limitations: Observational retrospective or cross-sectional study design (1, 7, 9) Unclarities related to exposure (1, 7, 9) Risk of selection bias (1, 9) Low response rate (7) No comparison with non-Arctic population (1, 7, 9)
Risk factors for diseases	No evidence of an increased presence of risk factors for disease on Svalbard Low evidence for Norwegian population, very low for Russian population	2–6, 12, 14, 18	Low to very low	Limitations: Failure to adequately control the confounding (4, 5, 14, 18) Unclear eligibility criteria with a risk of selection bias (2, 3, 6, 12) Unclarity with regards to the completeness of the follow-up research (2, 3) No CI provided for repeated measures with a risk of imprecision (2, 3, 12, 14)
Traumatic injuries	The population on Svalbard has a significantly higher risk of being involved in snowmobile accidents or experiencing polar bear attacks than the population on the Norwegian mainland The population on Svalbard runs a significantly lower risk of being involved in other types of traffic accidents and in violent episodes	10–11, 15–17	Quality of evidence concerning Norwegian residents (15,17) on Svalbard (16): moderate Quality of evidence concerning visitors (15,17) and comparisons between Norwegian residents of Svalbard and Harstad (16): very low	Limitations: Flawed measures of exposures and outcomes (10, 15, 16, 17) Failure to adequately control the confounding (10, 15, 16, 17) Advantages: High accuracy of parts of the studies
Search and rescue (SAR)	-	-	-	-
GRADE-CERQual Summary of findings
Outcome	Summary of review finding	Studies contributing to the review finding	CERQual assessment of confidence in the evidence	Explanation of CERQual assessment
Disease	-	-	-	-
Risk factors for diseases	-	-	-	-
Traumatic injuries	Adolescents are aware of how accidents occur and how to avoid them	8	Very low confidence	Serious concerns regarding relevance reduces the confidence in the review findings. Only approximately 10% of the study participants were from the study area
Search and rescue (SAR)	The local population is a resource in SAR situations on Svalbard SAR actors expect the local population to contribute to SAR operations	13	High confidence	A solid study with reliable findings