|Background NOVA did this evaluation of the National Pollen Forecast Service on commission from the Norwegian Asthma and Allergy Association (NAAF) and the Norwegian Directorate of Health from August 2017 thru May 2018. Several studies indicate that allergies and hypersensitivity have become more widespread (Meld. St. 19, (2014- 2015) - Report to the Storting (white paper) on public health). Asthma is the most dramatic and most frequently mentioned of all illnesses due to allergic reactions. In the year 2000, it was the most frequent cause of hospitalization of Norwegian children (Carlsen 2001). In a cross-sectional study among children, aged 7-14 in a Northern Norwegian region in 2008, the incidence of self-reported asthma was 18 percent (Meld. St. 19, 2014-2015). According to the whitepaper on Public Health, several studies show that the lifetime incidence of hay fever (rhinitt) is about 25 percent among school aged children and 30 percent among youth in puberty (Meld. St.19, 2014-2015). Although the National Pollen Forecast Service in Norway started about 1975, it had still not been evaluated. The Norwegian Asthma and Allergy Association (NAAF) has continuously operated the service. It is of importance for people of all ages that the National Pollen Forecast Service is optimal. Allergic reactions to pollen from Alder, Hazelnut, Salix, Birch, Grass, and Common mugwart and some other plants and substances (e.g. dust) affect all age groups and, are overall a significant public health problem. If untreated such allergies can cause absence from kindergarten, school and workplaces, worsen other illnesses, and trigger asthma. For many of those with severe pollen allergies, reduced participation in school and work life activities will also cause reduced learning, ability to work and work-satisfaction. Topics in this report The main topics in this report are: The current Pollen Forecast Service and its usefulness for different groups of users. Collection and analysis of pollen, usefulness in other areas Expertise in Norway, Sweden and Denmark Suggestions for future developments in the collection and use of pollen data. Design and Methods The assignment was carried out using several types of evaluation and research methods. One method has been a literature study, the second implementation of an online survey among users of the pollen alert and the third method has been interviews with health professionals and other experts. Main findings A review of former studies is described in chapter 3, they are in the list of references at the end of this report. Several articles describe newer measurement methods, number of pollen traps in regional areas or large cities and, studies of user-feedback about their ailments during the pollen season. One article illustrates the difficulties the British healthcare system has handling pollen allergies, especially among the youth population. The literature review also refers to several articles regarding the efforts to get a better understanding of the effects of the daily pollen alerts for different groups of users, within and outside Europe. Some studies also include more automatized and semi-automatic ways of measuring pollen (especially in Germany and some other European countries). In Europe, there has been a lot of research and trials of different systems for pollen-notification and user assessments of various types of apps. Parts of this literature can be of substantial importance when planning the future of Norwegian pollen alerts and may possibly also be useful in the development of Scandinavian pollen forecast services. Both the literature that discusses user experiences and the literature on modern automated methods may be of interest in this regard. The online survey (in Chapter 4) invited a random sample of 5000 subscribers to the Norwegian Pollen Forecast Service’s mailing list to participate in the survey, which had both open-ended questions and questions with fixed reply categories. We received 570 responses. Although this is a low response rate, that does not permit decisive conclusions, the responses especially from the open-ended questions gave useful information. Two out of three respondents were women. All age groups 18 and older were among the respondents and in general, they had a high level of education. Many respondents were long time users of the service, almost a fourth had used the services for more than a decade. Essentially the users are pleased with the Pollen Forecast Service. They use it often; many use it once or more a week during the pollen season. In response to the question: if the pollen Forecast Service he /she used had helped in regards to reducing their ailments, almost 45 per cent answered yes. About 40 percent answered somewhat, and a relatively small share, 12 percent answered no. The users had many and useful suggestions for further development and improvements of the service. One important input is that they wish there were more pollen traps/metering stations. Relatively many say that the alert does not always match what they experience in their home areas. This may be due to both the fact that there are not enough metering stations in our long country with climatic variations, and that many are not aware of the delays in analysis of samples from the pollen traps (due to delayed mail service). The main findings from the interviews are discussed in chapter 5. There were 24 semi-structured half-hour interviews with healthcare personnel and other experts. Sixteen interviews were with healthcare personnel, five were with Norwegian experts, two with foreign experts, and one informant was a user of the services. The main impression from the interviews is that the healthcare professionals, the Norwegian experts and the individual user are very pleased with the Norwegian pollen alert service. The Norwegian experts gave information about the Norwegian forecast service during the interview. The Norwegian pollen alert system has been run by the NAAF since it started in 1975, although there has been an increase in the number of traps and types of pollen they report. Today the Norwegian pollen forecasts are based on information from 12 traps located in 12 different regions that they send alerts for. Samples from the whole country are analyzed at a laboratory at NTNU (a university in central Norway) and the pollen researchers there prepare the forecast for the coming days. Thereafter, they produce daily statistics for each trap. In 2006, the Norwegian Directorate of Health began to contribute financially to the pollen alert service. In 2013, the Pollen Forecast Service was included in the National Budget, but the annual allotted amount in has remained the same from 2013 -2017. Norway uses the same type of traps that are used in other European countries. Since the same type of pollen traps are used in European countries and the pollen samples are analyzed in comparable ways, cross national studies on the importance of pollen forecasts for allergy sufferers can be conducted. Informants, among both experts and the health professionals, have suggestions for service improvements. An increase from the 12 pollen traps used today is desirable, since Norway is a vast country with meteorological and topological challenges. Some believe that if patients had better knowledge about the pollen alerts and used them more actively, some could be spared the additional suffering they go through because they do not use the alerts systematically enough. Several also acknowledge the importance of communication between doctors / nurses and patients and that it could be improved regarding pollen forecasts. The Danish pollen forecast system resembles the Norwegian; a national asthma and allergy association runs the service and they receive financial support from public health authorities. The association also has a webpage that publishes the pollen forecast amongst other topics. Denmark has two pollen traps, one in Copenhagen and one in Jutland. The trap in Jutland is partially automized, it has a motorized microscope that is monitored remotely. There is no need to mail the samples to Copenhagen to analyze them. Samples from both traps are collected and analyzed the same day and are made public simultaneously. The Danes also would like more pollen traps, preferably five; one in each of Denmark’s five regions. The Swedish service is organized in a different way than the Norwegian service. The Swedish asthma and allergy association does not run the Swedish service, even though it is partially government funded. The Swedish pollen alert system is managed by a laboratory at the Swedish Museum of Natural History, which is a government agency. There are 20 pollen traps in Sweden and collection of data from them is divided between three laboratories. The traps and the laboratories are funded in various manners by different levels of public authorities (national, regional and municipal). There is a website that has the forecasts from all of the Swedish pollen traps, gives information about an app, the three laboratories that monitor the pollen traps and how funding is organized. The Swedish asthma and allergy association has a policy document with suggestions on how to develop and secure future Swedish pollen alerts. Among their suggestions is an increase in the number of Swedish pollen traps to 25. Implications and recommendations Although Norway has had pollen forecasts since 1975, the service has never been through an external evaluation before. A significant majority of the service users, health care professionals and other experts we have been in touch with, are pleased with the current pollen alert service in Norway. However, they also state that there are ways to improve the services. There is a clear desire to increase the number of pollen traps. Norway has 12 pollen traps, and the number has been the same for several years. In Sweden, which this project was to include briefly, there are currently 20 pollen traps. The Swedish asthma and allergy associationâ€˜s policy memorandum from 2017, states that they want to increase the number of traps to 25. Chapters 4, 5 and 6 argue that there currently are not enough pollen traps in Norway. The reasons why there should be an increase of 5-6 pollen traps in Norway are explained. According to the experts we interviewed 18 pollen traps would require three research positions. My recommendation is to continue analyzing the samples at one laboratory, as it is done now. The analysis is done at the biology department of a university (NTNU), where they have two experienced researchers doing the job. Since NAAF has so much experience in running the service, and has accumulated a lot of user experience, it seems appropriate that the organization should continue to be the responsible body in this field. The Norwegian, Swedish and Danish pollen researchers expect that monitoring the pollen traps will be automized within a foreseeable future, as mentioned they have already started in Denmark. Based on the views presented in chapters 4 and 5 in this report, we recommend that Norway should have 20-25 pollen traps, at the latest within a 4-5-year period. An expert group should perhaps examine the need for additional pollen traps in the coming years. Continuing current research on automization of pollen traps and using satellite-data of vegetation is deemed important. Projects of that type should be continued. Another important issue assessed in this evaluation is the itemization of the Pollen Forecast Service in the national budget. Keeping the allocation of funds for the Pollen Forecast Service in the national budget has advantages; it would ensure the continuation of this important service targeting a major health problem. The results in this report also show that the NAAF are pleased that the forecast service is in the national budget. However, they are less satisfied with the lack of price adjustments since the Pollen Forecast Service was included in the National Budget in 2013. Thus, in terms of real value, there has been a reduction in the funding. We have made some comparisons with Sweden where public support of the services is divided in various ways and in addition, they have contributions from volunteers and private funders. Our assessment is that the Swedish organization of the service is less predictable and manageable than what is considered desirable for the Norwegian Pollen Forecast Service. Informants, both in the online-survey and interviews wanted quicker alerts from the sampling. As it is now, the samples are often more than a day old by the time they reach the laboratory at NTNU for analysis. This is because the analysis of samples from the 12 Norwegian pollen traps is done manually. In Denmark, the results are made public without this delay, because they have automated traps. Other European countries have tested a similar system. The experts we interviewed assumed within a few years there will be more electronic treatment of samples. Norway has more pollen traps than Denmark, and should test such methods and gain experience with acquiring results quicker. Several informants are requesting forecasts with a longer time span than the current two-day forecast. Since weather forecasts span several days, they believe it should be possible for pollen forecasts as well. Bearing in mind that it is advisable for allergy sufferers to start taking their medication about a week before expected exposure, subscribers of email- alerts and health personnel want forecasts that cover a longer period. There is, as shown in the report, a bit of research about pollen alert systems and circumstances that influence pollen alerts. Assessment of available research and suggesting areas in need of more research were to be part of the evaluation. Based on information from our informants and the review of existing international research, there are indications are that one pollen trap is insufficient in populated cities to capture another likely problem with variaÂtions in pollen within cities in addition to high air pollution. An area for further research is pollen in larger city environments (larger cities in a Scandinavian context). It is of importance to public health to acquire more knowledge about the development of pollen and pollution (pollution can enhance the allergic reactions to pollen for people with allergies) in areas with large populations. There is some uncertainty and probably some disagreement among health personnel regarding at what age children and youth are capable of using pollen alerts (e.g. the pollen app) and administering their own medication. It is important to gain more knowledge about whether children and youth use the pollen alerts and if they get the alerts. It may also be worth finding out if the use of, and usefulness of pollen alerts varies with other characteristics such as education, social background and immigrant background. Research that can show how climate change influences future pollen dispersion in the Scandinavian countries is also important. In this regard, research regarding the prevalence and dispersion of ragweed pollen in Scandinavia should be monitored and if necessary initiated. As of today, one assumes that the plant does not survive Norwegian winters, but the plant is found in both Denmark and southern Sweden. In Germany, Hungary, France and Switzerland pollen from ragweed is a major cause of allergy suffering and the experts we interviewed believe that a warmer climate will allow the plant to spread northward to a greater extent in the years to come.