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REPORT REPORT Terhi Hulkko Outi Lyytikäinen Sari Jaakola Markku Kuusi Jani Puumala Petri Ruutu (eds.) Terhi Hulkko, Outi Lyytikäinen, Sari Jaakola, Markku Kuusi, Jani Puumala, Petri Ruutu (eds.) Infectious Diseases in Finland 2010 ISSN 1798-0070 National Institute for Health and Welfare P.O. Box 30 (Mannerheimintie 166) FI-00271 Helsinki, Finland Telephone: +358 20 610 6000 www.thl.fi 39 | 2011 39 | 2011 Infectious Diseases in Finland 2010 © Publisher National Institute for Health and Welfare (THL) Department of Infectious Disease Surveillance and Control P.O. Box 30 (Mannerheimintie 166) 00271 Helsinki, Finland Phone: +358 20 610 6000 http://www.thl.fi Editors: Terhi Hulkko, Outi Lyytikäinen, Sari Jaakola, Markku Kuusi, Jani Puumala and Petri Ruutu. In addition to commentary, the report includes figures and tables that are not employed in our regular reporting. Distributions by gender, age and region are available on our website. The figures for some of the diseases in the National Infectious Diseases Register (NIDR) will still be updated after the figures have been published in print. Up-to-date figures are available at http://tartuntatautirekisteri.fi/tilastot Layout: Kati Tiirikainen, Luovinet Osk (http://www.verkkokettu.net) Infectious Diseases in Finland 2010. National Institute for Health and Welfare, Report 39/2011 ISSN 1798-0070 (printed) ISSN 1798-0089 (PDF) Juvenes Print Tampere 2011 Infectious Diseases in Finland 2010 contents RESPIRATORY INFECTIONS • 7 Influenza A ............................................................................................................................................... 7 Influenza B ............................................................................................................................................... 7 RSV .......................................................................................................................................................... 8 Legionella ................................................................................................................................................. 8 Whooping cough ...................................................................................................................................... 9 Adenovirus.............................................................................................................................................. 10 Parainfluenza .......................................................................................................................................... 10 Mycoplasma ............................................................................................................................................ 11 Chlamydial pneumonia........................................................................................................................... 11 GASTROINTESTINAL INFECTIONS • 12 Salmonella .............................................................................................................................................. 12 Campylobacter........................................................................................................................................ 14 Yersinia ................................................................................................................................................... 15 Shigella ................................................................................................................................................... 15 Enterohaemorrhagic Escherichia coli (EHEC) .......................................................................................... 15 Norovirus................................................................................................................................................ 16 Rotavirus ................................................................................................................................................ 16 Enterovirus ............................................................................................................................................. 17 Listeria .................................................................................................................................................... 17 Clostridium difficile.................................................................................................................................. 18 Food- and water-borne outbreaks............................................................................................................ 18 HEPATITIDES • 20 Hepatitis A ............................................................................................................................................. 20 Hepatitis B.............................................................................................................................................. 20 Hepatitis C ............................................................................................................................................. 20 SEXUALLY TRANSMITTED DISEASES • 23 Chlamydia .............................................................................................................................................. 23 Gonorrhoea ............................................................................................................................................ 23 Syphilis ................................................................................................................................................... 24 HIV and AIDS ....................................................................................................................................... 24 ANTIMICROBIAL RESISTANCE • 26 MRSA .................................................................................................................................................... 26 VRE........................................................................................................................................................ 26 ESBL ...................................................................................................................................................... 27 Invasive pneumococcal disease ................................................................................................................ 29 MYCOBACTERIAL INFECTIONS • 30 Tuberculosis ............................................................................................................................................ 30 OTHER INFECTIONS • 33 Haemophilus .......................................................................................................................................... 33 Meningococcus ....................................................................................................................................... 33 MMR diseases (measles, mumps, rubella) ............................................................................................... 33 Puumala virus ......................................................................................................................................... 34 Report 39/2011 National Institute for Health and Welfare 3 Infectious Diseases in Finland 2010 Tick-borne encephalitis (TBE) ................................................................................................................ 34 Tularemia ................................................................................................................................................ 34 Pogosta disease ........................................................................................................................................ 35 Borrelia (Lyme disease) ........................................................................................................................... 36 Malaria and other travel-related infections .............................................................................................. 36 Blood and CSF findings in children ........................................................................................................ 38 Blood and CSF findings in adults ........................................................................................................... 43 AUTHORS • 59 4 Report 39/2011 National Institute for Health and Welfare Infectious Diseases in Finland 2010 Introduction No significant changes occurred in national or international cooperation in the surveillance and control of infectious diseases in 2010. Evaluation of the impact of the 2009 pandemic, development of the required surveillance systems and updating of pandemic contingency plans were key areas of action at all levels in Finland. The WHO appointed an independent external working group to evaluate actions based on the International Health Regulations since they entered into force in 2007 in general and WHO actions based on them in connection with the 2009 influenza pandemic in particular. The working group will submit its report at the WHO general assembly in 2011, and this will be a cornerstone for the development of surveillance and control of infectious diseases internationally in biothreat scenarios in the near future. At the national level, the 2009 pandemic highlighted the importance of setting up a geographically and demographically comprehensive procedure for the surveillance of respiratory infections in the primary health care system. A pilot study conducted in 2010 with daily collecting of reasons for primary health care visits produced promising results. Vital for achieving high-quality surveillance are comprehensive registration and correct encoding of reasons for visits as a part of the routine clinic work. Virological monitoring must be closely linked to surveillance of reasons for clinic visits. An online alert system for suspected food- and water-borne epidemics was introduced for the use of health, food and environmental authorities at the beginning of 2010. Extending the vaccination programme to include rotavirus vaccinations (2009) and pneumococcal vaccinations (2010) for small children on the one hand and the adverse side effects of the pandemic vaccinations on the other further emphasised the importance of surveillance for the diseases to be prevented through the vaccination programme, of the coverage of the vaccination programme and of the analysis of its effectiveness. EPIDEMIOLOGICAL OVERVIEW 2010 While the epidemic peak of the 2009 pandemic came well before new year 2010, there was no significant surge in influenza in 2010 until the end of the year. At that time, the number of diagnoses of the H1N1 virus, which caused the 2009 pandemic and integrated into the seasonal influenza cycle, becoming the dominant virus of the year, and of influenza B virus began to increase. Extending influenza vaccinations in the autumn to include also health care personnel proved to be a challenging effort, not least because of the emerging adverse side effects of the Pandemrix vaccine, even if in the previous pandemic season of 2009–2010 vaccination coverage of health care personnel was in many areas quite high, according to unpublished data. The RSV epidemic in 2010 was unexpectedly late and of record intensity. The number of cases of whooping cough remained low, as has been the case since the whooping cough vaccinations were changed in 2005, and the epidemic cycle of a few years that used to be prevalent no longer exists. The number of mycoplasma findings increased in autumn 2010, heralding a robust epidemic for winter 2010–2011. The epidemiological profile of gastrointestinal infections caused by salmonella and campylobacter remained unchanged. The number of Yersinia and EHEC diagnoses decreased on the previous year. Norovirus infections remained very common, but the number of rotavirus infections declined sharply, probably because of the introduction of rotavirus vaccinations into the national vaccination programme for small children in 2009. The number of enterovirus infections, causing multiple types of syndromes, was clearly higher than in previous years. The incidence of Clostridium difficile infections has decreased substantially in recent years, indicating that enhanced preventive measures at health care institutions are taking effect. Exceptionally, there were a number of outbreaks of food poisoning in 2010 in which uncooked red beet was the suspected source. A toxin was indicated as the cause because of the rapid onset and short duration of symptoms. The number of listeria infections was considerably higher than in previous years, which was a cause for concern. Enhanced monitoring of fish production and publicity aimed at groups at risk from listeria were undertaken. There were fewer cases of hepatitis A than ever before, and also fewer cases of hepatitis B than at the beginning of the decade. This reflects a higher activity in vaccinations and the impact of syringe and needle exchange programmes on users of intravenous drugs. There are indications that the average age of patients contracting hepatitis C is rising. Report 39/2011 National Institute for Health and Welfare 5 Infectious Diseases in Finland 2010 In venereal diseases, the number of cases of chlamydia remained stable at a high level, continuing to emphasise the need for enhancing the prevention of venereal diseases. Treatment of gonorrhoea is complicated by the fact that more than half of the strains found are resistant to quinolones, forcing the use of thirdgeneration cephalosporins. Tourism to Russia is a key source of cases of syphilis, and its incidence is highest in the hospital districts of southeastern and southern Finland. The number of new HIV infections remained high, as in previous years. What is worrying is that an increasing percentage of newly diagnosed patients are willing to disclose how they contracted the infection. Pneumococcus strains in blood and cerebrospinal fluid cultures are very often resistant to erythromycin, and the percentage of strains with reduced susceptibility to penicillin continues to rise, being almost one in four in 2010. The prevalence of strains of Escherichia coli and Klebsiella pneumoniae with reduced susceptibility to third-generation cephalosporins, which usually are ESBL strains, continues to increase in both blood cultures and other types of samples. Findings of gram-negative bacterial strains highly resistant to carbapenems are also increasing. The number of cases of MRSA has remained stable in recent years. The number of cases of tuberculosis has varied widely in recent years, being clearly lower in 2010 than in the previous year. The percentage of cases of tuberculosis accounted for by immigrants is increasing, placing new challenges on the physicians treating them and on those responsible for disease prevention. Instructions on screening and preventing infectious diseases among refugees and asylum seekers were issued in 2010, and a new national recommendation on the investigation of contacts in cases of infectious tuberculosis was issued recently; there are about 100 cases of the latter in Finland annually. Although indigenous occurrences of MMR diseases in Finland were eliminated 15 years ago, travel-related cases of measles and mumps and potential secondary transmission in Finland underline the importance of high vaccination coverage in preventing epidemics. The area where tick-borne encephalitis is endemic in Finland is gradually expanding. The number of borrelia infections matched that of the previous peak year, 2009. A new feature in this annual report is a summary of the incidence of the principal travel-related infections. Of the more than 20 patients who fell ill with falciparum malaria no one had used malaria prophylaxis. The number of cases of dengue fever is constantly 6 Report 39/2011 National Institute for Health and Welfare increasing, which demonstrates the importance of protecting against mosquitoes when travelling to the tropics or other warm climates. The number of severe bacterial and fungal infections detected by blood culture in adults exceeded 11,000 per year for the first time ever. The overall number of bacterial and fungal infections found in children by blood and cerebrospinal fluid culture remained stable. The proportion of pneumococcus was significant, and it will be interesting to monitor in the next few years how the pneumococcal vaccination introduced for small children in autumn 2010 as part of the national vaccination programme will affect this. Helsinki, 19 April 2011 Petri Ruutu Head of Department Infectious Diseases in Finland 2010 Respiratory infections • The incidence of influenza did not peak until the end of the year in 2010. • The RSV epidemic was bigger than ever but occurred later than expected. • The number of cases of Mycoplasma pneumoniae increased in autumn 2010, heralding an epidemic in the winter of 2010–2011. INFLUENZA A The year 2010 was a mild one for influenza A, especially considering that influenza A epidemics usually occur immediately after the New Year, in January and February. In spring 2009, a new type of pandemic influenza virus, A(H1N1) 2009, appeared and quickly spread worldwide. The virus was first found in Finland in May 2009, but the epidemic proper did not start until early October 2009. The epidemic caused by the pandemic influenza A (H1N1) 2009 virus peaked in late 2009 (October and November 2009), and only isolated cases were reported to the National Infectious Diseases Register (NIDR) between December 2009 and March 2010. In all, 418 findings of influenza A virus were reported to the NIDR in 2010 (12,564 in 2009), of which 228 (7,652) were laboratory-confirmed findings of pandemic influenza A (H1N1) 2009. Between January and March, 17 findings of pandemic influenza A (H1N1) 2009 were reported, following which the first laboratory-confirmed finding in the autumn was not reported until late November. Between early November (week 44) and the end of 2010, 383 findings of influenza A were reported, of which 211 were laboratory-confirmed findings of pandemic influenza A (H1N1) 2009. A significant percentage of the cases diagnosed were in the age groups 15 to 19 and 20 to 24. The percentage of men among these cases was disproportionate, probably because these age groups include young men undergoing national service. Influenza virus epidemics tend to hit garrisons first, and this happened in 2010 too. In the age group 19 to 24, the coverage of vaccination against pandemic influenza A (H1N1) virus (Pandemrix) was no more than 30% to 36%. The low vaccination coverage among young men of national service age and close proxim- ity favouring the spreading of infections in garrisons ensured the quick and efficient spreading of the epidemic. The pandemic influenza A (H1N1) viruses that caused epidemics were similar in their antigen profile to the vaccine virus A/California/07/2009, although their genetic diversity was increasing. The strains that were circulating in Finland towards the end of the year represented three genetically distinct groups, one of them a group found in the southern hemisphere as early as in summer 2010. Despite the genetic mutations undergone by the viruses, being infected by or vaccinated against the pandemic influenza A (H1N1) 2009 virus can be considered to have provided good antigen protection. In addition to findings of the pandemic influenza A (H1N1) 2009 virus, 190 cases of influenza A infection of unknown subtype were reported to the NIDR in 2010. Of these, 172 were reported in November and December. Some of these cases are known to have been caused by viruses of the influenza A (H3N2) subtype, which are similar in their antigen profile to the influenza A/Perth/6/2009 (H3N2) vaccine virus present in the seasonal vaccination administered in autumn 2010. However, at the European level A (H3N2) virus infections were rare during the 2010–2011 season. INFLUENZA B In 2010, the number of influenza B cases reported to the NIDR totalled 140 (2009: 769), nearly all of them (121) in December. There are two lineages of influenza B, Victoria and Yamagata. The prevalence of these two lineages has varied over the years. In Report 39/2011 National Institute for Health and Welfare 7 Infectious Diseases in Finland 2010 H1N1V 7500 2000 H3N2 1800 H3N2 1600 1400 1200 1000 H3N2 H3N2 800 H1N1 600 H3N2 H1N1 H3N2 H1N1V H3N2 400 H3N2 H1N1 200 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Figure 1. Cases of influenza A by epidemic virus type per month, 2000–2010 (no. of cases). 8 2009 and 2010, epidemics worldwide were principally caused by viruses in the Victoria lineage, although there were also some findings of the Yamagata lineage in China in 2010. The seasonal influenza vaccination in autumn 2009 and 2010 included a virus from the Victoria lineage as its influenza B component, B/ Brisbane/60/2008. The first case of influenza B infection in the 2010–2011 season was reported in the last week of October, and the number of cases began to increase and exceeded the epidemic threshold after mid-December. Viruses from both lineages have been found in Finland. The Yamagata lineage was prevalent at the beginning of the epidemic, but findings of the Victoria lineage increased steadily thereafter. Cases of influenza B infection reported in 2010 were equally distributed among age groups, from children to the elderly. minor epidemic in the spring, with a more violent attack in the following winter (Figure 3). The incidence of RSV varied by hospital district (5–104/100,000), most likely caused by differences in the use of laboratory diagnostics. As always, nine out of ten RSV cases involved children aged 0 to 4. Even though infections occur in all age groups, babies and small children constitute the majority of cases leading to hospitalisation and laboratory diagnostics. Reliable quick tests for RSV diagnostics have been developed for use at health centres, outpatient clinics and hospitals. In hospital conditions, RSV is easily transmitted between patients. Quick tests make it easier to identify RSV infections and therefore to prevent further transmission. Specialised virus laboratories increasingly use genetic replication methods for diagnosing RSV. RSV LEGIONELLA In 2010, 2,597 cases of RSV confirmed with laboratory tests were reported to the NIDR (2009: 1,611). The record number of cases was due to the fact that the onset of the epidemic expected before the New Year was delayed until January, and the epidemic did not peak until March. In Finland, RSV follows a regular two-year pattern; in uneven years, there is a In 2010, 31 cases of Legionella were reported to the register on the basis of laboratory findings. The diagnosis was based on detection of antigen in the urine in 9 cases and in sputum in one case, on bronchoalveolar lavage fluid culture or PCR in 4 cases, and on serological methods in the rest. In further investigations, the clinical picture was found to be consist- Report 39/2011 National Institute for Health and Welfare Infectious Diseases in Finland 2010 700 Yamagata 600 500 Victoria, Yamagata 400 Victoria 300 Victoria, Yamagata 200 Victoria, Yamagata Yamagata 100 Yamagata Yamagata Yamagata Yamagata 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2009 2010 Figure 2. Cases of influenza B by epidemic virus type per month, 2000–2010 (no. of cases). 1400 1200 1000 800 600 400 200 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 Figure 3. Cases of RSV per month, 2000–2010 (no. of cases). ent with legionellosis in 14 cases; in other words, the patient had radiologically diagnosed pneumonia. All 9 patients whose Legionella was confirmed by a urinary antigen test had pneumonia. Of the legionellosis cases, 8 were men and 6 were women. They were aged between 35 and 80; only two were under 50. One person died of legionellosis in 2010. About 60% (8 out of 14) of the legionellosis patients had spent time abroad before falling ill. The accommodation data of these patients were reported to ELDSNET (European Legionnaires’ Diseases Surveillance Network), which collects data on travel-associated legionellosis. WHOOPING COUGH In 2010, the number of whooping cough cases reported to the NIDR totalled 343 (6.4/100,000). This was somewhat higher than the all-time low recorded in 2009 (267). Of these patients, 14 were under 12 months old, 9 of them under three months old (vaccinations against whooping cough begin at the age of three months in the national vaccination programme). The diagnosis of all patients under 12 months old was based on a PCR test, while the majority of cases were diagnosed from antibody testing. Report 39/2011 National Institute for Health and Welfare 9 Infectious Diseases in Finland 2010 250 200 150 100 50 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Figure 4. Cases of whooping cough per month, 2000–2010 (no. of cases). Patients under 20 years old accounted for 57% of all cases. This percentage was lower in previous years, being 49% in 2008 and 39% in 2009. Once again, incidence of whooping cough varied greatly by hospital district (1–14/100,000), being highest in the Central Finland hospital district and lowest in the Kainuu hospital district. ADENOVIRUS In 2010, 900 confirmed cases of adenovirus infection were recorded (2009: 622). Most of these were recorded in March and between August and November (more than 100 cases per month), but there were plenty of adenovirus infections in the summer too, particularly among small children. More than 50 types of adenovirus are known. Some cause respiratory infections, some intestinal infections. Adenoviruses are common pathogens in infants and small children; they occur more rarely in adults. Significant adenovirus epidemics occur in the Defence Forces, often following an influenza epidemic. This is what happened in March 2010, a typical time of year for a peak in adenovirus infections in garrisons. Unlike in spring 2010, there were only a few cases of adenovirus infection following the pandemic of 2009. Respiratory tract adenovirus infections are diagnosed using an antigen test, genetic replication test or extracted mucus culture or similar method (sputum or bronchoscopy sample), or serologically. The largest number of cases was in the age group 0 to 4, with significant numbers also in age groups 5 to 9, 15 to 19 and 20 to 24, the latter including young men of conscription age. 10 Report 39/2011 National Institute for Health and Welfare Adenovirus infections among conscripts tend to appear as epidemics whenever new arrivals enter service, particularly in February and March. There were fewer cases in the higher age groups, and their distribution throughout the year was even. PARAINFLUENZA Parainfluenza viruses are grouped under one heading in the NIDR, even though laboratories usually differentiate between parainfluenza viruses 1, 2 and 3. In 2010, 393 parainfluenza infections were confirmed (2998: 378), most of them in the age group 0 to 4. The months with the highest numbers of cases (more than 50 per month) were February, March and December. Parainfluenza infections are found in all age groups. A child’s first parainfluenza infections may lead to a severe condition, even requiring hospitalisation. In an older child or an adult, a parainfluenza infection is typically much milder in its symptoms. It often presents as an ordinary upper respiratory tract infection and requires no laboratory diagnostics. In special groups, however, such as immune deficiency patients, parainfluenza viruses can cause quite serious symptoms. In 2010, as earlier, high numbers of parainfluenza infections were found in infants, small children and, to some extent, young schoolchildren. Parainfluenza virus type 3 causes minor epidemics in the summer and autumn nearly every year. By contrast, parainfluenza viruses types 1 and 2 do not cause epidemics every year. Parainfluenza viruses, especially type 1, typically cause laryngitis in small children. Infectious Diseases in Finland 2010 MYCOPLASMA CHLAMYDIAL PNEUMONIA There were 1,927 cases of Mycoplasma pneumoniae recorded in 2010. The number of cases of Mycoplasma pneumoniae increased in autumn 2010, heralding an epidemic in the winter of 2010−2011. The most recent such epidemics in Finland occurred in winters 2004–2005 and 2005–2006. In Denmark, epidemics of Mycoplasma pneumoniae have been observed regularly at intervals of four to six years ever since the 1950s, and there too the number of cases increased beginning in summer 2010. The largest number of cases relative to population (more than 60/100,000) were found in the Varsinais-Suomi and Vaasa hospital districts, whereas the largest number of cases in absolute terms was found in the hospital district of Helsinki and Uusimaa. As expected, most of the findings were in patients aged 5 to 19. In 2010, 214 laboratory-confirmed cases of Chlamydia pneumoniae were recorded, 60% of them between October and December. This heralded an increase in the incidence of cases in winter 2010–2011. The number of annual cases is the highest recorded since 2004. The largest number of cases relative to population was found in the Vaasa hospital district (19/100,000), whereas the largest number of cases in absolute terms was found in the hospital district of Helsinki and Uusimaa and the Varsinais-Suomi hospital district. The findings were for the most part from patients aged 5 to 14 and thus most probably involved a primary infection diagnosed on the basis of an IgM positive test result. A large number of cases was also found among patients aged 40 to 50; most of these were probably reinfections, where IgM is only found in some cases. As such, diagnosis requires accurately timed paired samples and testing for elevated IgG levels. 350 300 250 200 150 100 50 0 2000 2001 2002 2003 2004 2005 Mycoplasma pneumoniae 2006 2007 2008 2009 2010 Chlamydia pneumoniae Figure 5. Cases of Mycoplasma pneumoniae and Chlamydia pneumoniae per month, 2000–2010 (no. of cases). Report 39/2011 National Institute for Health and Welfare 11 Infectious Diseases in Finland 2010 Gastrointestinal infections • The number of rotavirus cases recorded in 2010 was less than half of what the annual number used to be before vaccinations were begun in September 2009. • The enterovirus epidemic season began exceptionally early, in July. • A record number of Listeria monocytogenes infections was recorded. • The number of cases of Clostridium difficile continued to decline. SALMONELLA In 2010, there were 2,438 reported cases of salmonella (2009: 2,329), 55% of them in women patients. Annual incidence in the entire country was 45/100,000 population. The incidence was highest in the South Karelia hospital district (55/100,000) and lowest in the Länsi-Pohja and Päijät-Häme hospital districts (21/100,000 and 25/100,000, respectively). The incidence was highest in the age group 20 to 24 (70/100,000) and lowest in the age group over 75 (8/100,000). The most common salmonella serotypes were Enteritidis (854 cases), Typhimurium (246 cases), group B (112 cases) and Stanley (106 cases). There were 9 diagnosed cases of the Typhi serotype, which causes typhoid; 2 cases of S. Paratyphi A, which causes paratyphoid; and 5 cases of S. Paratyphi B. In all the cases where travel information was available (14 cases), the patients had contracted the infection abroad. India, Thailand and Nepal were the most common sources for S. Typhi and S. Paratyphi infections. Out of all cases of salmonella, 336 (16%) were of domestic origin, roughly the same percentage as in earlier years. The incidence of domestic infections was 6/100,000. Domestic salmonella infections were caused by 55 different serotypes. The leading four serotypes were Typhimurium (39%), Enteritidis (13%), Thompson (4%) and Infantis (3%). The majority (54%) of the domestic cases of Typhimurium were of the endemic FT 1 phage type. The second most common phage type (14%) was FT U277. The FT 1 strains are divided into nine genotypes, most of which, as in previous years, were of the genotype STYMXB.0098, which is susceptible to antimicrobi- 12 Report 39/2011 National Institute for Health and Welfare als. Strains in this genotype were further typed using the MLVA method based on differences between repeated sequences in DNA; the majority (64%) presented with the MLVA profile 3-16-NA-NA-0311. There were only 44 cases caused by the domestic Enteritidis serotype. These were divided into 14 phage types, most of them (more than half ) of the types FT 4B, FT 2, FT 4 and FT 8, and into 17 genotypes, the most common being SENT 15. Information on whether a salmonella infection was acquired in Finland or abroad remained lacking for 56 (2.3%) cases in 2010. The total number of foreign salmonella infections was 2,030, and the incidence was 38/100,000 population. The salmonella infections acquired abroad represented 122 serotypes. The S. Enteritidis serotype caused 778 (38%) of the cases with foreign origin. The next most common serotypes acquired abroad were Typhimurium (142 cases), group B (103), Stanley (98) and Virchow (77). The leading countries of acquisition were Thailand (30%), Egypt (12%), Turkey (11%) and Spain (5%). There were 665 strains phage-typed from the foreign Enteritidis strains and 99 from the Typhimurium strains. The most common phage types of S. Enteritidis were FT 21 (18%, mostly from Turkey), FT 1 (16%, from 23 different countries) and FT 4 (10%, from Turkey, Estonia, Latvia and Egypt), while those of S. Typhimurium were FT NST (17%, from 13 different countries), FT 120 (14%, mostly from Thailand) and FT 193 (13%, from Thailand and Kenya). Infectious Diseases in Finland 2010 Table 1. The most common serotypes of salmonella cases, 2000–2010 (excluding S. Typhi and S. Paratyphi) (no. of cases]. 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Infection acquired abroad (Source: NIDR) Salmonella Enteritidis 1052 1243 904 887 758 834 879 735 1066 657 778 Salmonella Typhimurium 205 143 115 155 183 194 141 246 198 166 142 Salmonella group B 45 32 33 23 37 38 55 93 166 119 103 Salmonella Virchow 50 79 55 67 74 88 80 135 115 90 77 Salmonella Hadar 125 96 69 58 22 33 45 22 24 17 27 Salmonella Newport 20 57 47 40 53 47 66 57 76 54 54 Salmonella Infantis 23 34 20 16 33 39 31 54 31 42 42 Salmonella Braenderup 49 45 50 26 16 16 32 53 37 39 38 Salmonella Stanley 44 63 65 67 105 113 116 175 136 111 98 Salmonella Corvallis 7 21 10 40 39 60 56 59 70 68 42 Other 602 563 476 483 520 483 526 644 687 576 629 Total 2222 2376 1844 1862 1840 1945 2027 2273 2606 1939 2030 Domestically acquired infections (Source: Bacteriology Unit, THL) Salmonella Typhimurium 124 152 222 137 132 241 170 150 80 134 132 Salmonella Enteritidis 52 63 42 61 81 75 69 61 49 48 44 1 26 1 1 1 Salmonella Hvittingfoss Salmonella Hadar 17 11 4 3 3 4 3 1 Salmonella group B 5 2 3 2 7 1 4 11 2 2 2 3 Salmonella Infantis 7 19 4 4 4 11 6 3 Salmonella Newport 11 5 3 16 8 3 9 Salmonella Saintpaul 12 1 3 4 2 3 Salmonella Agona 27 41 16 12 32 11 Salmonella Poona 8 1 4 9 2 5 Salmonella Virchow 15 8 3 2 5 11 Salmonella Thompson 1 Salmonella Ohio 27 3 4 2 5 7 8 3 2 12 7 2 9 23 70 9 8 2 5 2 2 40 15 2 2 14 12 8 6 6 4 2 1 1 2 2 8 5 12 Salmonella Abony 5 3 15 Salmonella Stanley 5 9 1 Salmonella Give 1 1 Salmonella Bovismorbificans 3 2 Salmonella Reading 1 Salmonella Mikawasima 3 15 2 1 1 6 Salmonella Braenderup 1 4 1 7 2 2 12 7 7 2 7 5 5 12 8 6 7 1 4 39 3 2 1 2 4 2 2 1 1 2 1 1 1 31 25 2 5 23 1 2 2 1 7 Other 28 39 45 45 43 49 49 52 55 36 78 Total 325 390 406 310 336 443 397 372 374 309 336 145 102 107 86 111 151 92 150 81 56 Country of acquisition not specified Total 224 Report 39/2011 National Institute for Health and Welfare 13 Infectious Diseases in Finland 2010 1000 900 800 700 600 500 400 300 200 100 0 2000 2001 2002 2003 2004 Salmonella 2005 2006 2007 2008 2009 2010 2008 2009 2010 Campylobacter Figure 6. Salmonella and campylobacter cases by month, 2000–2010 (no. of cases). 700 600 500 400 300 200 100 0 2000 2001 2002 2003 2004 Culture 2005 2006 2007 Antibody Figure 7. Yersinia enterocolitica culture and antibody findings, 2000–2010 (no. of cases). CAMPYLOBACTER In 2010, the NIDR received 3,944 notifications of campylobacter infections, 104 cases fewer than in 2009. Campylobacter jejuni remained the single most common type of campylobacter (2,052 cases); there were 195 reported cases of C. coli, and no fewer than 1,696 cases where the campylobacter species was not specified. The hippurat test used to distinguish between species has been abandoned in some laboratories, because it cannot correctly identify all strains. The incidence in the entire population was 14 Report 39/2011 National Institute for Health and Welfare 74/100,000. Men accounted for 53% of the cases, and the highest number of cases was in the age group 25 to 49. Incidence was highest in the hospital district of Helsinki and Uusimaa (116/100,000). The seasonal variation was typical for campylobacter: incidence was highest in July-August (Figure 6). Of the cases in 2010, 528 (13%) were domestic in origin, although almost one in three cases lacked data on the country of acquisition. Leading sources for foreign infections were Thailand (528 cases), Turkey (236), Spain (222) and India (152). Infectious Diseases in Finland 2010 YERSINIA SHIGELLA Yersinia enterocolitica In 2010, the incidence of shigellosis was 3.0/100,000. There were 160 reported cases, 72 in men and 88 in women. Only a very small percentage of the cases was found in patients aged under 20 (14 cases) or over 65 (7). More than half (85) of the cases were reported in the hospital district of Helsinki and Uusimaa. Five hospital districts had no diagnosed cases. Of the total, 140 infections (88%) were acquired abroad and 12 in Finland. In 8 cases, the country of acquisition was not specified. The most common countries of origin were Egypt (58 cases) and India (38). The prevailing shigella species were Shigella sonnei (97 cases), followed by S. flexneri (44) and S. boydii (12). There were seven reported cases of S. dysenteriae (no shigatoxin-producing serotypes were among the pathogens). Eighty per cent of the strains were multi-resistant (R to at least 4 out of 12 antimicrobials tested), and 29% were completely resistant or had reduced susceptibility to ciprofloxacin (MIC 0.125–12 mg/l). Moreover, five strains were completely resistant to cephotaxim (some are estimated to produce ESBL enzyme). In 2010, the NIDR received 458 notifications of Yersinia enterocolitica, 14% fewer than in 2009 (534). In 2010, the incidence in the entire country was 8.6/100,000 population. Based on the cases recorded in the NIDR, the incidence was highest in the age group 45 to 49 (13.5/100,000) and lowest in age groups under 15 (less than 4/100,000). There is great regional variation in the number of Yersinia enterocolitica cases, with the highest incidence reported in the Kainuu hospital district (21/100,000 population); Åland and the Itä-Savo hospital district reported no cases. Typing data were reported for less than half of Y. enterocolitica cases in 2010, which makes it difficult to draw conclusions about the percentages of the various bio/serotypes. However, a separate study found that Y. enterocolitica bacteria isolated from elderly patients tend to be non-pathogenic strains, while pathogenic strains are over-represented in small children. Yersinia pseudotuberculosis The number of Yersinia pseudotuberculosis cases (57 cases) continued to decrease, having been 80 in 2009. In 2010, the incidence in the entire country was 1.0/100,000 population. The number of cases is too low to reliably indicate any regional variation. Ten hospital districts diagnosed no cases at all in 2010. Outbreaks cause variation in the annual incidence of cases of Y. pseudotuberculosis. ENTEROHAEMORRHAGIC ESCHERICHIA COLI (EHEC) In 2010, 20 microbiologically confirmed cases of enterohaemorrhagic Escherichia coli (EHEC) were reported to the NIDR (0.37/100,000). This is fewer than in 2009 (31). Foreign acquisition accounted for six of the cases. Ten of the patients were women and ten were men; 11 were under the age of 15, and 300 250 200 150 100 50 0 2000 2001 2002 2003 2004 Culture 2005 2006 2007 2008 2009 2010 Antibody Figure 8. Yersinia pseudotuberculosis culture and antibody findings, 2000–2010 (no. of cases). Report 39/2011 National Institute for Health and Welfare 15 Infectious Diseases in Finland 2010 four of these were in the 0 to 4 age group. HUS syndrome was diagnosed as a complication in four of the patients. The O157-serogroup strains were divided into two common phage types (FT 4 and FT 8) and caused a total of 9 cases. There were 11 non-O157serogroup cases, divided into seven O groups, some of them extremely rare (O2, O104, O121, O146, OX182). Most of the strains had the genes to produce both Stx1 and Stx 2 shigatoxin. Four small clusters of infections were identified among people who lived in the same household or had otherwise been in close contact with the index patients. NOROVIRUS breaks that occurred in 2010 were institutional outbreaks. This also explains the high incidence among the elderly. Unlike in previous years, the norovirus outbreaks in 2010 were caused almost exclusively by the new norovirus variant GII.4 2010, which arrived in Finland in December 2009. This variant is a recombination of two earlier GII.4 variants that emerged in 2006 and 2008. With the appearance of the new variant, the previously dominant norovirus variant in Finland, GII.4 2006b, became rare; it only caused a handful of individual outbreaks 2010. There were also individual outbreaks caused by other genotypes (GI.4, GI.b, GI.7, GII.b, GII.7) in 2010. Norovirus has become one of the most common causes of food- or water-borne outbreaks in the 2000s. The number of food poisoning outbreaks decreased considerably in comparison with the frozen raspberry scenario of 2009. Noroviruses of genotype I are commonly associated with food-borne outbreaks, and the year 2010 was no exception, as GI.4 was identified as the main cause of food poisoning. In 2010, there were 2,740 reported cases of norovirus; 1,561 of the patients (57%) were women. The incidence rate, 51/100,000, was higher than in the previous year. Over 80% of the cases were reported between January and April. More than half (57%) of the patients were over 75 years of age, but infections were diagnosed in all age groups. The incidence was highest in the province of Lapland (108/100,000) and lowest on Åland (25/100,000). There was less variation in the other provinces than in previous years, the incidence being 45–59/100,000. ROTAVIRUS The year 2010 was the fourth year running when new variants of the norovirus GII.4 genotype, emerging every one or two years, caused a widespread epidemic in Finland, as indeed they did elsewhere in the world. As in previous years (2007–2009), most of the out- In 2010, 426 cases of rotavirus infection were reported, less than half of the usual level in previous years. However, as in previous years, boys made up the majority of patients (56%). The epidemic of early 2010 was clearly less potent than previous ones. 3000 2500 2000 1500 1000 500 0 2005 2006 2007 Figure 9. Cases of norovirus infection, 2005–2010 (no. of cases). 16 Report 39/2011 National Institute for Health and Welfare 2008 2009 2010 Infectious Diseases in Finland 2010 The first rotavirus vaccine was launched in Finland in the summer of 2006. The vaccine was initially underused, but by 2008 one child in three was receiving a rotavirus vaccination, paid for by the parents. The rotavirus vaccine was finally added to the national vaccination programme in September 2009. At the end of the follow-up period, the first children to have received the vaccination in the programme were 18 months old. Because the incidence of the infection is in any case low during the first months of life, probably because of antibodies received from the mother, the incidence at this time only reflects the programmebased vaccinations of one cohort of newlyborns. The incidence was again clearly highest in children under five years of age (120/100,000). However, this has fallen to one fourth of what it was 10 years ago. With increasing vaccination of infants, the percentage of cases in older age groups will increase. In 2010, just over 16% of all cases were in patients aged 5 or over, whereas this figure was never higher than about 10% in previous years. Cases were reported in all hospital districts, the incidence being highest in the Lapland, Vaasa and Northern Bothnia hospital districts. The incidence in Lapland was ten times higher than in the south, and the incidence in the age group under 5 years has not really decreased at all since the addition of the vaccine to the vaccination programme. It is possible that in Lapland the virus circulates more virulently, vaccination coverage is lower, or sampling is more efficient. The rotavirus serotypes that most commonly cause illness in humans are G1P[8], G2P[4], G3P[8], G4P[8] and G9P[8]. The illnesses caused by the various serotypes are very similar. Rotavirus diagnoses are mainly based on quick tests that do not indicate the type of virus. In the future, however, it will become increasingly important to identify the type of rotavirus so that it can be established which serotypes cause infections regardless of the vaccination. ENTEROVIRUS In 2010, 560 cases of enterovirus infection were reported, considerably more than in 2009 (364) or 2008 (354). Men accounted for 313 (56%) of the cases. About one third (183, 33%) of the patients were under the age of 10, and the majority of cases involved patients under the age of 20. The epidemic season began exceptionally early, in July, and enterovirus infections were particularly prevalent in late summer and in the autumn. Several extensive aseptic meningitis epidemics caused by the Echo 30 virus were ob- served in Kanta-Häme, North Karelia and Southern Savo in 2010. Also, there were clusters of hand, foot and mouth disease in North Karelia, featuring not only the typical body rash with sores but also severe headache (meningitis). These clusters turned out to have been caused by coxsackie viruses CVA-6 and CVA-10. Enteroviruses cause infections of the central nervous system (aseptic meningitis, encephalitis, myelitis, neuritis, etc.), myocarditis and typical enteroviral conditions (hand, foot and mouth disease, epidemic myalgia, etc.) Upper respiratory tract infections have also been found to be ‘typical’ enteroviral conditions. The reports in the NIDR contain no information on symptoms. Human enteroviruses are divided into four categories, A to D (abbreviated HEV-A to HEVD). Rhinoviruses, which cause the common cold, are nowadays included in the enterovirus family. Enterovirus diagnostics is increasingly based on the RT-PCR method, which does not distinguish between virus serotypes. Therefore, a stool culture remains the recommended and most useful way of diagnosing an enterovirus infection. Stool cultures also enable the monitoring of the possible circulation of polio viruses in the population; this monitoring is important and necessary even in Finland. LISTERIA Listeria monocytogenes infections were clearly more numerous in 2010 than in previous years (71 cases). The median age in these cases was 73 years, and 38 of the patients (54%) were men. There were five reported pregnancy-related infections. The listeria cases were spread out across the country. In 17 (24%) of the cases, the patient died within one month of the diagnosis. The annual number of cases varied between 18 and 46 from 2000 to 2008; in 2009, 33 cases were reported. Listeria was isolated from blood culture in 64 (90%) cases; in seven cases, listeria was diagnosed from cerebrospinal fluid; in four of these, listeria was found also from blood culture. Serotypes 1/2a, 4b, 1/2c and 1/2b caused 50 (70%), 16 (23%), 2 (3%) and 1 (1%) of the cases, respectively. More than 30 different PFGE genotypes of listeria were identified. Listeria monocytogenes causes severe infections in infants, pregnant women, patients with immune deficiency and the elderly. The incidence of listeriosis has increased worldwide in recent years, especially among elderly people who have other factors sensitising them to the condition. The infection is food-borne; Report 39/2011 National Institute for Health and Welfare 17 Infectious Diseases in Finland 2010 risk foods include products made of unpasteurised milk and other animal- or plant-based foodstuffs and ready-to-eat foods that are in cold storage for a long time. Listeria bacteria may also occur in the food production environment, contaminating food products after the heat treatment in the production process. Finland’s risk foods include vacuum-packed salt-cured and cold-smoked fish products. A study conducted in 2010 found that the majority of listeriosis patients had a medication or underlying illness that compromised their immune system. Nearly two thirds of the patients had consumed salt-cured or cold-smoked fish. Most of the cases were individual ones. The most common genotype of listeria by far in the cases was type 96 (13 cases). Half of the type 96 listeria case patients who were interviewed had consumed salt-cured or cold-smoked fish before falling ill. At the same time, the same listeria genotype was discovered at a Finnish fish processing facility, where an extensive renovation was then carried out. This genotype has become more widespread in Finland since 2006, being regularly isolated for instance from Finnish fish products. This is, however, a relatively common genotype worldwide and can be found in a variety of foods, not just fish. In December 2010 and January 2011, four cases of listeriosis of genotype 62 were reported in Finland. All the patients were women aged over 80. All of them had access at their respective nursing homes at Christmas to salt-cured salmon prepared by a specific fish processing facility. A bacterial strain of genotype 62 identical to that found in the patients was isolated from the salt-cured salmon served at one of the nursing homes involved. This listeria genotype was found at the same time in products of other fish food producers as well. To rectify the situation, local authorities sent inspectors to perform extra inspections and sample-taking at fish processing facilities. The National Institute for Health and Welfare cooperated with the Finnish Food Safety Authority Evira in publicising repeatedly during 2010 that listeria causes severe illnesses in at-risk groups. Authorities supervising institutional kitchens were provided with information on foods that may carry a risk of listeria infection. CLOSTRIDIUM DIFFICILE Clostridium difficile has been a finding reportable to the NIDR from the beginning of 2008. More than 6,000 cases were reported in 2010 (2009: more than 7,000; 2008: more than 8,000), out of which 4,804 involved a toxin-producing strain (2009: 5,700; 2008: 6,301). Almost 60% of patients diag- 18 Report 39/2011 National Institute for Health and Welfare nosed with C. difficile were women, and half were 75 years of age or older. Over 150 (3%) cases of toxinpositive strains were reported in under-15-year-olds (2008–2009: 2% to 3%), and almost one third of these had been isolated in infants under 12 months old. There was significant regional variation in the incidence (45–165/100,000), with the hospital districts of Satakunta, Lapland and Kymenlaakso showing the highest incidence. In severe cases or when a local outbreak is suspected, clinical laboratories have been asked to send C. difficile strains for further examination by the THL reference laboratory. There continued to be great local variation in the number of strains sent: although all hospital districts reported toxin-positive C. difficile cases, only 11 of them sent strains for genotyping. The total number of strains sent was only about 5% of the number of infectious disease reports (228 out of 4,442). Of the strains examined, 16% were of PCR ribotype 027, which so far has been found in at least nine hospital districts: Helsinki and Uusimaa, Varsinais-Suomi, Satakunta, Central Ostrobothnia, North Ostrobothnia, Pirkanmaa, Kanta-Häme, Kymenlaakso and South Karelia. In addition to PCR ribotype 027, other ribotypes were detected that may be possible hyper-producers of toxin. Severe cases were caused not only by PCR ribotype 027 but also by ribotypes 001, 005, 018 and 056. So far, more than 90 different PCR ribotypes have been detected in Finland, of which about 30 have been identified as genotypes previously reported internationally. FOOD- AND WATER-BORNE OUTBREAKS From the beginning of 2010, municipal epidemic investigation working groups entered notifications of suspected food- and water-borne epidemics directly into the register IT system jointly maintained by the National Institute for Health and Welfare and the Finnish Food Safety Authority Evira, known as the RYMY information system. In the course of the year, 53 such notifications were entered. These included several cases of illnesses associated with the consuming of uncooked red beet. Several other intestinal infection clusters were investigated as well. Epidemics caused by uncooked red beet In 2010, seven reported food poisoning outbreaks were suspected to have been caused by uncooked red beet. These outbreaks involved more than 100 people, all of whom had fallen ill after consuming uncooked red beet in shredded form at a workplace or Infectious Diseases in Finland 2010 school canteen. The most common symptoms were abdominal pain and nausea; headaches, fatigue and vomiting were also reported. The onset of symptoms was rapid (less than an hour after eating), and their duration was brief (a few hours). The clinical profile was consistent with intoxication. No findings that could explain the symptoms were discovered in the patient samples. Microbiological examination of the red beets also showed no traditional food poisoning microbes or toxins. Because of these outbreaks, the Finnish Food Safety Authority Evira recommends that red beet should be cooked before consumption. Higher than usual number of severe listeria infections A higher number of listeriosis cases than usual was reported to the NIDR in 2010. This is discussed in more detail in the Listeria section on page 17. In 2010, 13 cases of serotype 1/2a, genotype 96 listeria were found in Finland. Interviews revealed that half of the patients had consumed salt-cured or coldsmoked fish before falling ill. At the same time, the same listeria genotype was discovered at a Finnish fish processing facility, where an extensive renovation was then carried out. This is, however, a relatively common genotype worldwide and can be found in a variety of foods, not just fish. In December 2010 and January 2011, four cases of listeriosis of serotype 1/2a, genotype 62 were reported in Finland. All the patients were women aged over 80. All of them had access at their respective nursing homes at Christmas to salt-cured salmon prepared by a specific fish processing facility. A bacterial strain of genotype 62 identical to that found in the patients was isolated from the salt-cured salmon served at one of the nursing homes involved. This listeria genotype was found at the same time in products of other fish food producers as well. The municipal supervisory authorities enhanced monitoring of fish processing facilities to clarify the situation. Yersinia enterocolitica O:9 caused gastroenteritis at Leppävirta In May 2010, 42 people contracted gastroenteritis at Leppävirta. Yersinia enterocolitica bio/serotype 2/O:9 was isolated from stool samples in seven of these cases. The bacteria strains were found to be identical using the MLVA method based on tandemly repeated DNA sequences. The Finnish Food Safety Authority Evira, through a PCR-based assay, found Yersinia bacteria in all samples of salads and shredded carrot recovered from the institutional kitchen associated with all of the cases in April and May. However, the presence of yersinia could not be confirmed by culture, so it could not be conclusively established that the salad and shredded carrot had been the cause of the outbreak. Salmonella Urbana cases in Finland, the Czech Republic and Latvia In January and February, a strain of Salmonella Urbana of a specific genotype caused 14 reported infections: seven around Finland, six in the Czech Republic and one in Latvia. Most of the patients were aged under 16, the age median being 5 years. The majority were boys. Three out of four of those who fell ill had to be hospitalised. An epidemic investigation was launched because of the severity of the symptoms and the rarity of the Salmonella Urbana serotype. The investigation was conducted by questionnaire in cooperation with the Czech and Latvian authorities, but no link between the cases could be established. No further cases were reported in any European country after early February. Other salmonella clusters Salmonella Typhimurium, phage type 1 (FT 1) and genotype STYM1 caused clusters of infections in August: 6 in Huittinen and 5 in Pori. This serotype, and specifically FT 1, is a Finnish domestic variant that is endemic in wild and domestic animals. This type of salmonella causes minor epidemics in Finland every year, principally in late summer. Some of the cases referred to here constituted a family epidemic. Another cluster of Salmonella Typhimurium FT 1 was found in February 2010, when genotype STYM28 caused 5 cases in Uusikaarlepyy. This is a genotype rare in Finland. In the summer (mainly in May), Salmonella Thompson caused 8 infections in western Finland. The strains were of genotype STMP 11, which had not been found earlier in Finland. Interviews indicated that the source of the infection was sprouts. Infections caused by Salmonella group E (3.10:-:1.5), genotype E2 were found in 9 patients in eastern Finland in July and August. This serotype is rare in Finland and has not caused epidemics previously. A Salmonella Mikawasima genotype SMIK3 infection was found in 6 patients in central Finland in November and December. The link between them was a specific health centre ward. Mikawasima is a serotype rare in Finland, but the same SMIK3 genotype also caused a cluster of infections among the personnel of a cruise ship in November 2008. Report 39/2011 National Institute for Health and Welfare 19 Infectious Diseases in Finland 2010 Hepatitides • There were fewer cases of hepatitis A than ever before. • Hepatitis B infections contracted from intravenous drug use have decreased conspicuously. HEPATITIS A In 2010, the NIDR received 14 notifications of hepatitis A (incidence: 0.3/100,000), fewer than in any previous year. The patients were equally divided, 7 men and 7 women. The median age in these cases was 33 years (variation 13–80). More than half of the cases (9) were diagnosed in the hospital district of Helsinki and Uusimaa, while 17 hospital districts had no diagnosed cases. Two infections were acquired in Finland and 10 abroad; in two cases, the country of acquisition was not specified. Hepatitis A cases have remained at a low level since 2002–2003, probably because of high vaccination coverage among travellers and at-risk groups. There are problems in differentiating between acute and chronic hepatitis B infections. In some cases, the diagnosis code and the laboratory test results in the reports are contradictory. The number of cases reported as acute is thus probably not entirely accurate, although the big picture and long-term trends are reliable. HEPATITIS C In 2010, 46 acute hepatitis B infections were reported (35 men and 11 women). The mode of transmission was given only for one in four cases. Of the cases where this was given, the mode of transmission was sexual contact in 15 cases and intravenous drug use in one case (Figure 10). About half of the cases involved a patient of foreign origin (born outside Finland or with non-Finnish citizenship). Infections acquired by a number of Finns abroad were also reported, although on the whole the hepatitis A and B combination vaccine used by travellers largely protects Finns travelling abroad. In 2010, 1,138 new hepatitis C (HCV) infections were reported to the NIDR, 66% of the patients being men and 34% women. This was 88 more than in 2009. The annual number of new HCV cases had been decreasing over the past decade before this slight upturn (Table 2). Similar findings have been made in prevalence studies conducted among intravenous drug users. The incidence of HCV among intravenous drug users is so high (c. 55%) that bringing it down is a slow process that will take a decade at least even in the best case where risks are brought under immediate control. However, because it is difficult to distinguish acute HCV infections from those contracted years ago, trends in case numbers must be viewed with caution. The number of cases of acute hepatitis B increased by 9 in 2010 on 2009. However, this is still much lower than in the peak years of the 1990s, even if the falling trend has been levelling off in the past five years (Figure 10). The number of cases involving infection In the majority of hepatitis HCV cases (596) in 2010, the mode of transmission reported was intravenous drug use (Table 2). The number of unclear cases decreased slightly on previous years, though it was still high (406 in 2010). In general, these cases are con- HEPATITIS B 20 through intravenous drug use have decreased the most rapidly, due to drug users and their family members being vaccinated and an effective needle and syringe exchange programme being put into place. Report 39/2011 National Institute for Health and Welfare Infectious Diseases in Finland 2010 sidered to be related to intravenous drug use because HCV is not transmitted easily through sexual contact and no community transmission has been detected. Regionally, the incidence of hepatitis C has remained fairly stable in recent years, being the highest in the provinces of Southern Finland and Oulu (Figure 12). Health counselling for intravenous drug users should be further enhanced in high-incidence areas to reduce the number of infections. The number of annual cases in the age groups 15 to 19 and 20 to 24 have remained stable or decreased (Figure 11). This may be a sign that health counselling for intravenous drug users and the related preventive work has decreased the risk of infection most effectively in younger age groups and that hepatitis C is now more typically contracted at a later age, after prolonged intravenous drug use. Indeed, the number of annual cases in age groups over 25 is increasing (Figure 11). 120 100 80 60 40 20 0 1998 1999 2000 2001 2002 2003 2004 2005 Injecting drugs 2006 2007 2008 2009 2010 Sex Figure 10. Acute hepatitis B cases involving intravenous drug use and sexually transmitted infections, 1998–2010 (no. of cases). Table 2. All cases of hepatitis C according to physicians’ reports, organised by means of transmission, 2000–2010. 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Injecting drugs 937 826 717 637 615 629 578 468 574 516 596 Sex 40 42 45 46 60 62 72 68 74 70 73 Perinatal 6 3 3 1 11 5 5 3 11 9 10 Blood products 25 20 19 22 18 24 7 21 20 2 9 Other 31 31 28 35 31 34 37 28 34 31 38 Unknown 700 565 560 524 506 490 469 577 429 422 406 Total 1739 1487 1372 1265 1241 1244 1168 1165 1142 1050 1132 Report 39/2011 National Institute for Health and Welfare 21 Infectious Diseases in Finland 2010 700 600 500 400 300 200 100 0 2000 2001 0−14 2002 2003 15−19 2004 2005 20−24 Figure 11. Hepatitis C by age group, 2000–2010 (no. of cases). Hepatitis C, cases/100,000 population <10/100,000 10–15/100,000 16–20/100,000 21–25/100,000 >25/100,000 figure 12. Incidence of Hepatitis c in finland 2010. 22 Report 39/2011 National Institute for Health and Welfare 2006 25−29 2007 30−34 2008 2009 35− 2010 Infectious Diseases in Finland 2010 Sexually transmitted diseases • The annual number of gonorrhoea cases continued to increase, as did the fluoroquinolone resistance of the strains found. • The number of HIV infections contracted through heterosexual contact and in sexual contact between men both increased. • Most of the infections contracted by men through heterosexual contact were acquired abroad. CHLAMYDIA (CHLAMYDIA TRACHOMATIS) GONORRHOEA (NEISSERIA GONORRHOEAE) In 2010, the number of chlamydia cases reported to the NIDR totalled 12,825 (241/100,000), slightly less than in 2009 (13,317). About 59% of the patients were women. The highest incidence of chlamydia cases was found in the hospital districts of Lapland (331/100,000), Pirkanmaa (280/100,000), and Helsinki and Uusimaa (280/100,000). The majority of the cases involved women aged 15 to 24 (73%) and men aged 20 to 29 (66%). As previously, among under-20-year-olds, women constituted a significantly larger group of patients (2,449) than men (719). The annual number of cases of gonorrhoea continued to increase. The NIDR received 257 notifications of gonorrhoea (4.8/100,000). Men accounted for 75% of the cases. The majority of cases (79%) were diagnosed among patients aged 15 to 39. More cases were found in the age groups under 25 than in previous years. The highest incidence was in the hospital district of Helsinki and Uusimaa (11.4/100,000), where the incidence has been steadily increasing since 2007 (7.6/100,000). The country of acquisition was specified in 82% of the cases; 42% of the infections had been acquired abroad. The most common country of 4000 3500 3000 2500 2000 1500 1000 500 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Men, 15−19 years Men, 20−24 years Men, 25−29 years Women, 15−19 years Women, 20−24 years Women, 25−29 years 2010 Figure 13. Chlamydia cases in the young adult age groups, 2000–2010 (no. of cases). Report 39/2011 National Institute for Health and Welfare 23 Infectious Diseases in Finland 2010 Table 3. Gonorrhoea infections acquired domestically and abroad, 2000–2010 (no. of cases). 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Finland 129 113 100 89 133 133 112 79 90 115 123 Russia 48 34 28 9 7 23 12 6 17 8 8 Estonia 7 3 5 2 6 1 - 2 - - 3 Thailand 18 17 31 27 38 30 42 44 34 36 45 Other 32 26 18 21 21 20 25 22 24 40 33 Unknown 50 54 53 41 47 33 45 42 35 40 45 Total 284 247 235 189 252 240 236 195 200 239 257 Table 4. Syphilis infections acquired domestically and abroad, 2000–2010 (no. of cases). 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Finland 54 32 25 30 22 25 21 56 57 69 36 Russia 80 49 22 18 16 22 18 17 26 18 26 Estonia 3 2 1 6 1 6 3 4 9 3 9 1 2 2 Somalia Thailand 1 1 Other 17 11 12 3 3 4 8 10 5 1 2 1 1 2 6 5 4 14 12 18 17 25 35 30 45 Unknown 49 63 67 62 58 68 67 79 75 67 84 Total 204 159 129 133 111 143 130 187 216 202 209 origin was Thailand (45 cases) (Table 3). Fluoroquinolone resistance in gonorrhoea continues to increase. In 2009, 72% of gonococcal strains were found to be resistant to ciprofloxacin (Finres 2009). SYPHILIS (TREPONEMA PALLIDUM) In 2010, the number of syphilis cases reported to the NIDR totalled 209 (3.9/100,000), which is nearly equal to the figure for 2009 (202). Sixty-four per cent of the cases were diagnosed in men. Patients aged 25 to 54 accounted for 68% of the cases. The incidence was greatest in the hospital districts of South Karelia (11/100,000), Kymenlaakso (6.7/100,000) and Helsinki and Uusimaa (6.5/100,000). The country of acquisition was specified in 60% of the cases, and of these 71% were acquired abroad, most often in Russia (26). HIV AND AIDS In 2010, 188 new HIV infections were reported to the NIDR, 70% of the patients being men and 30% women. This was 10 more than in 2009, matching the peak year 2006. By the end of the year, 2,778 new 24 Report 39/2011 National Institute for Health and Welfare HIV infections had been reported in Finland. There is a rising trend: infections reported in the 2000s constitute 60% of all HIV infections ever found in Finland. This increasing trend is due to an increasing number of HIV infections contracted in heterosexual contact and in sexual contact between men. The number of infections from heterosexual transmission in 2010 was 93 (2009: 96), 57 of them in Finns and 36 in foreigners. The number of HIV infections in this group has increased substantially in the 2000s compared to what it was before that, among both foreigners and Finns. Most of the foreigners diagnosed came from areas with a high prevalence of HIV and had contracted HIV before coming to Finland. Most of the infections contracted by Finnish men through heterosexual contact were also acquired abroad. The number of infections from sexual contacts between men in 2010 was 45, 32 of them in Finns and 13 in foreigners. This was about the same as in the two previous years. Infections from sexual contacts between men began to increase again at the beginning of the 2000s. This trend seems to have peaked over the past three years, however, even though the annual number of new cases is still high. A prevalence study among homosexual and bisexual men Infectious Diseases in Finland 2010 conducted in 2010 found a prevalence of 1.4% for HIV, significantly higher than in the population on average. The majority of HIV infections from sexual contacts between men were found in Finnish citizens and had been acquired in Finland. There were 6 cases of HIV associated with intravenous drug use in 2010, one Finn and 5 foreigners. It is important to note that only one Finn contracted HIV through intravenous drug use during the year. However, 6 further cases of HIV were found among drug users, the means of transmission being reported as sexual contact with an intravenous drug user. Effective preventive measures have kept infections from intravenous drug use at a low level following the HIV epidemic at the turn of the millennium. HIV infections in children are rare in Finland. One case of mother-to-child infection was reported in 2010; this child had been born abroad. A total of 13 mother-to-child HIV infections have been found in Finland in the 2000s, all but one of them of foreign origin. Mother-to-child transmission can be effectively prevented with medication during pregnancy. One HIV infection possibly transmitted by a blood transfusion was reported in 2010. The transfusion had been performed abroad. Only one other transfusiontransmitted HIV infection has been reported in the 2000s. There have been no reported cases of infection through blood products in Finland since HIV testing of donated blood began in 1985. The percentage of cases where the means of transmission is not known has grown steadily, from 13% on average in the 1990s to 22% in 2010. Of the cases where means of transmission was not reported in 2010, 40% also lacked a physician’s notification. In the remaining cases, the patient did not know or did not want to say how the infection had been contracted. A record number of HIV infections were found in foreigners in Finland in 2010: 80 cases, representing 43% of the annual total. Most of the foreigners diagnosed came from areas with a high prevalence of HIV and had contracted HIV through a heterosexual contact before coming to Finland. In the 2000s, HIV infections contracted by foreigners through sexual contacts between men and intravenous drug use have clearly increased, although in absolute terms the numbers are still rather low. In 2010, 33 cases of AIDS were diagnosed, and AIDS was the cause of death in 8 cases. The number of AIDS cases and deaths has remained similar since the introduction of effective combination drugs in the mid-1990s. By the end of 2010, 296 persons have died from AIDS. A significant percentage of the AIDS cases occurring in the 2000s were due to a late HIV diagnosis. In 2010, infection was detected late in about half of the cases (CD4 < 350). Late diagnosis weakens the treatment prognosis and increases the possibility of further infections. Changes in primary resistance were found in about 5% of the HIV virus strains in 2010. The comparable figure for Europe as a whole has been around 10% in recent years. 120 100 80 60 40 20 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Heterosexual transmission Injecting drug use Mother-to-child transmission Men having sex with men Blood products Not notified 2010 Figure 14. HIV cases by transmission group, 2000–2010 (no. of cases). Report 39/2011 National Institute for Health and Welfare 25 Infectious Diseases in Finland 2010 Antimicrobial resistance • The MRSA situation remained stable. • The number of VRE findings increased on the previous year. • There were considerably more ESBL findings than in 2009. • More carbapenemase-producing gram-negative bacilli were found than in previous years. • The percentage of pneumococcal strains with reduced susceptibility to penicillin increased, and the major proportion of pneumococcal strains remain resistant to macrolides. MRSA In 2010, 1,267 cases of methicillin-resistant Staphylococcus aureus (MRSA) were reported to the NIDR, about the same number as in the year before. Nearly one in four, 23% (2009: 25%), was diagnosed from samples taken from the nose or the nostrils. There were 26 MRSA cases found through blood culture (2009: 30) and two found through CSF culture. Of these invasive MRSA findings, 13 (46%) were in the Pirkanmaa hospital district (2.7/100,000) and 6 (21%) in the Helsinki and Uusimaa hospital district (0.4/100,000). The other hospital districts reported zero to three cases each, totalling 9. Most (18 out of 28) of the invasive cases occurred in patients older than 65, and none in children. As earlier, the hospital districts of Pirkanmaa and of Helsinki and Uusimaa reported the highest total figures. The incidence per 100,000 population was highest in the hospital districts of Pirkanmaa, Western Bothnia, Northern Karelia, Northern Savo and Kymenlaakso. A slightly smaller percentage of the findings than previously was in patients aged over 75, 42%. The number of MRSA cases in children remained stable (84–82). An MRSA strain isolated from the blood was typed in 1,300 individuals. There were 165 different spa types in the MRSA strains (2009: 155). The most common spa types were the same as in the previous year: t067 28% (2009: 26%), t172 14% (16%), t008 9% (7%), t002 4% (5%) and t032 3% (6%). Nine hospital districts found t067, Pirkanmaa having the most findings, and 16 hospital districts found t172. Strains of t008 and t002 were also typed using pulsed field gel 26 Report 39/2011 National Institute for Health and Welfare electrophoresis (PFGE). Both were sub-divided into several PFGE types. Nearly half (48%) of the t008 strains were of PFGE type FIN-25, an internationally known strain of MRSA originating in outpatient care (USA300), and more than one in three (36%) were of PFGE type FIN-7. Local clusters (MRSA strain isolated in more than 10 patients) also occurred in the Kymenlaakso (t223), Northern Karelia (t721) and Helsinki and Uusimaa (t2377 and t020) hospital districts. The most common spa type among patients over 75 was t067 (39%; 2009: 35%). Unlike in the previous year, the most common spa types among children were t223 (18%), t008 (12%, mostly of PFGE type FIN-25) and t172 (9%; 2009: 32%). An MRSA strain isolated from the blood was typed in 15 individuals: 6 were of spa type t067, the rest (9 out of 15) representing 8 different spa types. VRE In 2010, the number of vancomycin-resistant enterococcus (VRE) findings reported to the NIDR increased on the previous year. Most of the findings were in the Southwest Finland hospital district (68 out of 92), in patients aged over 75 (51 out of 92) and in women (56 out of 92). In the other hospital districts, the number of findings varied from one to 7. Three of the findings were from blood. VRE findings were typed in 88 individuals. All findings except for one were of the E. faecium species, and most of these were of the vanB type (82 out of 87). PFGE revealed that a new epidemic strain, VRE VIII, was spreading in the Southwest Finland hospital district, and this Infectious Diseases in Finland 2010 700 600 500 400 300 200 100 0 Central Finland Southern Bothnia Vaasa Central Bothnia Northern Bothnia Kainuu Western Bothnia Lapland Åland Helsinki and Uusimaa 700 600 500 400 300 200 100 0 Southwest Finland Satakunta Kanta-Häme Pirkanmaa Päijänne Tavastia Kymenlaakso Southern Karelia Southern Savo Eastern Savo Northern Karelia Northern Savo Figures 15a and 15b. MRSA cases by hospital district, 2000–2010 (no. of cases). was eventually the most common type of strain in 2010 (63 out of 88 cases). VRE IX was the cause of 4 cases in 2010, of which 3 were in the Southwest Finland hospital district. Both epidemic strains were also identified using multilocus sequence typing (MLST); their sequence types – ST17 (VRE VIII) and ST192 (VRE IX) – belong to the E. faecium CC-17 clone, which is internationally known as spreading in hospitals. The remaining 21 out of 88 cases involved isolated unique findings. ESBL Since the beginning of 2008, third-generation Escherichia coli and Klebsiella pneumoniae exhibiting reduced susceptibility or resistance to cephalosporin (I for intermediate and R for resistant, respectively) have been reported to the NIDR. The majority of these bacteria are enzyme-producing ESBL strains that split extended-spectrum cephalosporins and penicillin. In 2010, the majority of ESBL findings (2,258) were E. coli (2009: 2,158), with a small number (184) of Klebsiella pneumoniae (2009: 154). ESBL in E. coli was diagnosed in all age groups – almost 75% in women and over half in patients aged 65 years or more. The majority of diagnoses (71%, 1,794 out of 2,528) were made from urine. The largest number of cases was found in the hospital district of Helsinki and Uusimaa (912, 60/100,000), but the incidence was highest in the Southern Bothnia and Kymenlaakso hospital districts (71 and 63/100,000, respectively). There were considerably more ESBL findings in blood than in 2009 (112 vs. 77) (ESBL percentage Report 39/2011 National Institute for Health and Welfare 27 Infectious Diseases in Finland 2010 Table 5. MRSA-findings and their percentage of S. aureus blood culture findings, 1995–2010 (no. of cases and %). 1995 All MRSA findings S. aureus blood culture findings MRSA blood culture findings and the methicillin resistance of S. aureus (%) 89 627 2 (0,3) 1996 110 667 0 (0,0) 1997 121 747 4 (0,5) 1998 190 719 5 (0,7) 1999 212 813 8 (1,0) 2000 266 850 4 (0,5) 2001 340 887 4 (0,5) 2002 600 989 9 (0,9) 2003 859 981 7 (0,7) 2004 1478 1059 30 (2,8) 2005 1381 1013 27 (2,7) 2006 1330 1239 37 (3,0) 2007 1297 1179 32 (2,7) 2008 1772 1261 40 (3,2) 2009 1267 1288 30 (2,3) 2010 1267 1370 26 (1,9) Total 12579 15689 265 (1,7) Table 6. Antimicrobial resistance of Streptococcus pneumoniae findings in blood and CSF, 1998-2010 (no. of cases and %). Cases reported to the NIDR Studied strains Erythromycin (R) (%) Penicillin (I+R) (%) Multidrug resistance (%) 1998 561 84 3,6 0 0 1999 568 471 5,9 7,2 0 2000 601 439 8,0 3,7 1,4 2001 658 360 18,8 7,5 5,0 2002 599 594 16,3 8,0 3,7 2003 721 739 21,9 12,7 5,7 2004 748 748 20,5 9,6 3,7 2005 735 731 20,5 9,6 4,4 2006 741 760 27,9 16,4 5,4 2007 788 794 23,2 14,4 3,5 2008 924 930 24,5 17,7 3,4 2009 854 848 28,4 19,9 4,7 2010 827 819 28,6 23,4 1,7 I – reduced susceptibility: R – resistant; Multidrug resistance – strains simultaneously resistant to penicillin (I+R), erythromycin (R) and tetracycline (R) 28 Report 39/2011 National Institute for Health and Welfare Infectious Diseases in Finland 2010 of E. coli blood culture findings was 3.5%, or 112 out of 3,211, as opposed to 2.6% in 2009). The majority of the findings were made in the hospital district of Helsinki and Uusimaa. However, the incidence in blood findings was highest in the Pirkanmaa, KantaHäme and Kymenlaakso hospital districts. Over half of the ESBL cases reported that involved K. pneumoniae were also diagnosed in patients aged 65 years or over, but the percentage of women was smaller than with E. coli, being 58%. The majority of diagnoses (54%, 99 out of 184) were made from urine. The highest number of cases were found in the Northern Bothnia hospital district (60) and the hospital district of Helsinki and Uusimaa (37), but the incidence was highest in the Northern Bothnia and Kainuu hospital districts. There were 16 blood findings (2009: 6) (Percentage of ESBL in K. pneumoniae blood cultures was 3.2%, or 16 out of 504, as opposed to 1.3% in 2009). In 2010, genes encoding extended-spectrum betalactamases were specified in 135 bacterial strains. The strains had been collected for epidemic control, research, and confirmation of third-generation cephalosporin-resistance. The figure includes 107 E. coli and 28 K. pneumoniae strains. Out of the E. coli and K. pneumoniae strains isolated in 2010, 83% and 75%, respectively, had an extended-spectrum betalactamase of the CTX-M group. Changes in the ESBL genetic profile of E. coli were slight compared to 2009, but with K. pneumoniae the percentage of CTX-M genes had increased substantially from the 44% recorded in 2009. In 2010, carbapenemase-coding genes in 131 species of the Enterobacteriaceae genus were investigated. These strains had been sent for carbapenemase gene studies because of their reduced susceptibility to carbapenems. Of the strains examined, 9 (7%) had a carbapenemase gene: KPB, OXA-48, GES, NDM or VIM. All these genes were found in strains of K. pneumoniae. The VIM gene was the most common, being found in 5 separate strains isolated from 3 patients. For all K. pneumoniae strains with a carbapenemase gene, except for the GES gene, the patient had had contact with a hospital abroad (in Greece, India or Spain). strains were found to have metallo-beta-lactamase genes VIM and IMP. Patients from whom a strain of P. aeruginosa with the VIM carbapenemase gene was isolated had had contact with a hospital abroad, in Russia or Turkey. No similar link to hospitals abroad could be established for strains with the IMP gene. This means that strains with IMP metallo-beta-lactamase may already be present in Finnish hospitals. The majority of K. pneumoniae and P. aeruginosa strains with carbapenemase are, however, from abroad. The situation parallels that found in 2009 with the isolation of the first strains to contain a KPC gene. INVASIVE PNEUMOCOCCAL DISEASE (STREPTOCOCCUS PNEUMONIAE) In 2010, 827 cases (15/100,000) of invasive pneumococcal disease were reported (2009: 855, 16/100,000). As in previous years, the incidence was higher among men than among women (17 vs. 14/100,000). Regional variation was significant (8–26/100,000), which may be due to differences in how actively samples were taken. In 2010, the antimicrobial susceptibility of 819 pneumococcal strains isolated from invasive infections was analysed. Compared with 2009, 2010 saw the percentage of strains with reduced susceptibility to penicillin (MIC ≥ 0.125 mg/L) increase to 23%. The percentage of penicillin-resistant strains (MIC ≥ 2 mg/L) was 3.7%. The proportion of macrolide-resistant strains remained almost the same as in the previous year; 29% of invasive pneumococcal strains were resistant to erythromycin. Multiresistant (PEN IR – ERY R – TET R) accounted for 1.7% of the strains, which is slightly lower than in 2009. In 2010, one levofloxacin-resistant (MIC ≥ 8 mg/L) and two ceftriaxone-resistant (MIC ≥ 2 mg/L) strains were detected. In general, the changes in the susceptibility of invasive pneumococcus strains were minor when compared with 2009 findings. However, the percentage of strains with reduced susceptibility to penicillin continues to grow. In addition to the species in the genus Enterobacteriaceae, 60 strains of Acinetobacter baumannii and Pseudomonas aeruginosa were examined for carbapenemase genes because of their reduced susceptibility to carbapenems. The PCR test found a positive result in 25 (42%) of the cases. A. baumannii had genes of the OXA group which are typical for it (OXA-51, OXA-58, OXA-24 and OXA-23). P. aeruginosa Report 39/2011 National Institute for Health and Welfare 29 Infectious Diseases in Finland 2010 Mycobacterial infections • The percentage of immigrants among tuberculosis patients increased. TUBERCULOSIS (MYCOBACTERIUM TUBERCULOSIS) Tuberculosis surveillance Between 1995 and 2006, the registered tuberculosis cases included all cases confirmed by culture, as reported by the laboratories. In addition, cases reported by a physician were included, but only if the diagnosis was based on histology or a case of pulmonary tuberculosis was confirmed by positive sputum staining for tuberculosis bacilli. From 2007 onwards, following the case definition of tuberculosis cases in EU infectious disease surveillance, the statistics include all cases where a physician suspected tuberculosis on the basis of clinical evidence and decided to give full tuberculosis treatment even if the infection was not confirmed by microbiological tests or histology. The new criteria for compiling statistics do not affect the number of cases confirmed by laboratory tests or histology. Incidence of tuberculosis in 2010 There were 325 tuberculosis cases in 2010 (6.0/100,000), 21% fewer than in 2009 (411, 7.7/100,000); 242 (74%) of the cases in 2010 were pulmonary tuberculosis, and of these 88 (36%) had a positive sputum smear. In 2010, there were 258 cases of tuberculosis confirmed by culture, 15% fewer than in 2009 (303). As judged by physicians’ notifications, 22 patients (7%) had a previous history of tuberculosis diagnosed after 1950, when anti-tuberculosis medication became available. The increase in the overall number of tuberculosis cases in Finland in 2007 and 2008 compared to 2006 is explained by the introduction in 2007 of the broader EU case definition of tuberculosis. There was no increase in the number of cases of pulmonary tuberculosis confirmed by culture or positive sputum 30 Report 39/2011 National Institute for Health and Welfare smear in the aforementioned years. In 2009, there was a clear increase in the number of comparable, culture-confirmed cases, with a temporal correlation with a clear increase in the number of cases of foreign origin. The age distribution of tuberculosis cases was as follows: under 15, 6 cases (2%); 15 to 29, 64 cases (20%); 30 to 44, 41 cases (13%); 45 to 59, 51 cases (16%); 60 to 74, 59 cases (18%); and 75 or more, 104 cases (32%). No increasing trend has been found in children aged under 5 after the change in the vaccination programme in 2006. In 2010, the patient was foreign in 104 cases (32%), i.e. born abroad (in the absence of country of birth, citizenship other than Finnish). The age distribution of these was as follows: under 15, 4 cases (4%); 15 to 44, 81 cases (78%); 45 to 59, 13 cases (13%); and 60 or more, 6 cases (6%). Among these there were 72 cases (69%) of pulmonary tuberculosis and 32 cases (31%) of other forms of tuberculosis. Information on the patient’s country of birth or citizenship was missing in 5 cases (2%). The susceptibility of Mycobacterium tuberculosis strains in Finland remains good. Of all cultured strains, 93% had full susceptibility; 6 MDR strains were isolated (2%). However, while the latter were more resistant than before, none of them fulfilled XDR criteria. In 4 (1%) of the tuberculosis cases reported in 2010, the patient also had an HIV infection. Three of these were new HIV infections reported in 2010, and one had been reported earlier. Tuberculosis typing findings in 2010 All new strains of M. tuberculosis were genotyped in 2010 according to internationally harmonised typing methods (spoligotyping and MIRU-VNTR typing). Genotyping was used to trace the source of infection Infectious Diseases in Finland 2010 Table 7. Incidence of tuberculosis and percentage of culture-confirmed cases in Finland, 1995–2010 (no. of cases and %). Pulmonary tuberculosis Other tuberculosis All cases Cases Cases /100,000 Cases with positive sputum smear Cases with positive sputum smear /100,000 Cases Cases /100,000 Cases Cases /100,000 Cultureconfirmed cases Proportion of cultureconfirmed cases (%) 1995 436 8,6 241 4,7 217 4,3 653 12,8 475 72,7 1996 442 8,6 232 4,5 193 3,8 635 12,4 513 80,8 1997 360 7,9 185 3,6 197 3,8 557 10,9 442 79,4 1998 397 7,7 203 3,9 213 4,1 610 11,9 494 81 1999 405 7,8 185 3,6 188 3,6 593 11,5 510 86 2000 376 7,3 227 4,4 171 3,3 547 10,6 460 84,1 2001 312 6 150 2,9 181 3,5 493 9,5 411 83,4 2002 299 5,8 136 2,6 175 3,4 474 9,1 392 82,7 2003 290 5,6 144 2,8 122 2,3 412 7,9 348 84,5 2004 233 4,5 128 2,5 103 2 336 6,4 291 86,6 2005 269 5,1 136 2,6 100 1,9 369 7 321 87 2006 212 4,0 101 1,9 83 1,6 295 5,6 270 91,5 2007 235 4,5 93 1,8 111 2,1 346 6,6 250 72,3 2008 222 4,2 109 2,1 124 2,3 346 6,5 247 71,4 2009 295 5,5 96 1,8 116 2,2 411 7,7 303 73,7 2010 242 4,5 88 1,6 83 1,5 325 6,0 258 79 Table 8. Cases of tuberculosis in foreigners, 1995–2010 (no. of cases and %). Pulmonary tuberculosis 1995 Other tuberculosis All cases Cases in foreigners Proportion of foreigners (%) Cases in foreigners Proportion of foreigners (%) Cases in foreigners Proportion of foreigners (%) 25 5,7 13 6 38 5,8 1996 17 3,8 24 12,4 41 6,5 1997 23 6,4 23 11,7 46 8,3 1998 26 6,5 31 14,6 57 9,3 1999 25 6,2 21 11,2 46 7,8 2000 29 7,7 16 9,4 45 8,2 2001 34 10,9 28 15,5 62 12,6 2002 23 7,7 24 13,7 47 9,9 2003 36 12,4 13 10,7 49 11,9 2004 22 9,4 20 19,4 42 12,5 2005 28 10,4 24 24 52 14,1 2006 30 14,2 22 26,5 52 17,6 2007 45 19,1 28 25,2 73 21,1 2008 31 14 22 17,7 53 15,3 2009 81 27,4 43 37,1 124 30,1 2010 72 30 32 39 104 32 Report 39/2011 National Institute for Health and Welfare 31 Infectious Diseases in Finland 2010 in 35 different situations, including 89 cases of tuberculosis. Surveillance of the outcomes of tuberculosis treatment 2007–2009 Links between strains of tuberculosis were explored in a total of 32 cases in seeking the source of infection. Table 9 shows the distribution of treatment outcomes between 2007 and 2009. The group under surveillance consists of cases of pulmonary tuberculosis confirmed by culture, genetic replication or mycobacterial smear. An outcome evaluation is performed 12 months after the date of registration. This means that some of the outcome evaluation forms for 2009 have not yet been returned, which is why the surveillance is not yet as comprehensive as in previous years. In a cluster of 12 cases among homeless persons in the Tampere area, the strains of TB bacteria were found to be of the same type (SIT53). The possible connection of the Tampere TB cluster to the other cases caused by the SIT53 strain in Finland was investigated, and a further eight cases with genotypically similar strains were found in Kotka region. In this investigation, another cluster of cases among homeless persons with an identical strain (SIT40) was discovered in Tammisaari. Preliminary figures for 2009 show that the outcome was good in 65% of cases, a percentage slightly lower than in 2007 and 2008. It falls clearly short of the international target set by the WHO at 85%, but is on a par with the average for most EU Member States. Unlike in previous years, the group of good outcomes in 2009 included fewer cases fulfilling the criteria for microbiological full recovery than cases where treatment had been completed. In a cluster of cases among young immigrants from Africa, a previously unknown type (F404) was found to have caused altogether 14 cases. Three clusters in a hospital environment were investigated, involving a total of 4 cases of TB. The three strains isolated from medical care personnel in these cases were identical (SIT914). The mortality rate (before starting treatment or during treatment) was 17% in 2009, on a par with other EU Member States and similar to the situation in the two previous surveillance years. Laboratory contamination was suspected in three cases. In two cases, an obvious cross-contamination between samples was found using typing. Table 9. Results of surveillance of pulmonary tuberculosis treatment outcomes, 2007–2009 (no. of cases and %). Cases under surveillance 2007 2008 2009 203 191 246 144 (71%) 143 (75%) 159 (65%) 85 91 75 TREATMENT OUTCOME Favourable Cured 59 52 84 Non-favourable Treatment completed 44 (22%) 37 (19%) 44 (18%) Deceased 41 (20%) 33 (17%) 41 (17%) Treatment failure 1 1 0 Interrupted treatment 2 3 3 Missing 32 15 (7%) 14 (7%) 43 (17%) Transfer 3 2 13 Treatment continues at 12 months 7 9 6 Form not returned or treatment outcome was not indicated 5 3 24 Report 39/2011 National Institute for Health and Welfare Infectious Diseases in Finland 2010 Other infections • Repeated imported measles infections and further infections from these highlight the importance of good vaccination coverage. • The number of TBE cases contracted in mainland Finland is gradually increasing, but the risk of contracting TBE is the highest by far on Åland. • None of the patients who fell ill with falciparum malaria had used the appropriate prophylaxis. • The number of cases of dengue fever is constantly increasing, which demonstrates the important of protecting against mosquitoes when travelling to the tropics or other warm climates. • The number of severe bacterial and fungal infections detected by blood culture exceeded 11,000 per year for the first time ever. HAEMOPHILUS (HAEMOPHILUS INFLUENZAE) In 2010, there were 40 reported infections caused by the Haemophilus influenzae bacterium, diagnosed in blood or CSF. The majority of these (73%) were caused by unencapsulated strains. Serotype b was the pathogen in 4 adult patients and one child aged 3. The adults were in an age group for which the Hib vaccination was not yet included in the vaccination programme in their childhood. Children born in 1985 or later have received the Hib vaccine at the child care clinic. Since the beginning of 2005, under the revised vaccination programme, the Hib vaccination is administered as a component of a combination vaccine at 3, 5, and 12 months. The efficiency of the vaccination is monitored, and vaccination data are investigated for all children diagnosed with Hib. MENINGOCOCCUS (NEISSERIA MENINGITIDIS) The number of meningococcus infections detected in blood or CSF totalled 35 (0.65/100,000), which is about the same as in the previous two years. The serogroup distribution of the culture-confirmed cases (n=33) differed from previous years in that the absolute number and percentage of group Y cases had quadrupled: 14 of the cases (42%) were caused by group B meningococcus and 13 cases (39%) by group Y. There were 4 group C strains (12%). The age distribution of the cases was much the same as in previous years: 8 patients aged 0 to 4, 7 patients aged 15 to 20, and 16 patients aged 21 or over. No temporal or local clusters were detected. MMR DISEASES (MEASLES, MUMPS, RUBELLA) Five cases of measles were confirmed in Finland in 2010, two of them imported and three secondary cases. Measles was brought into the country by two young adults who had not been vaccinated against it, and they further infected three unvaccinated adults. The original patients had contracted measles in Senegal and Sicily. The genotypes of the measles viruses involved were B3 (Senegal) and D4 (Sicily), which are known to occur in or near the relevant areas. Four cases of mumps were confirmed, three in adults and one in a child. All patients were unvaccinated. One of the adults acquired the mumps in Thailand; the source of acquisition could not be established for the others. No cases of rubella were reported in 2010. Report 39/2011 National Institute for Health and Welfare 33 Infectious Diseases in Finland 2010 Table 10. Meningococcal infections by serogroup, 2000-2010 (no. of cases). Group A Group B Group C Group Y Group W135 Unknown Total 2000 30 11 2 3 2 48 2001 34 9 4 1 3 51 2002 36 6 4 1 2 49 2003 28 5 6 2 41 2004 29 5 4 4 44 2005 33 1 3 3 40 2006 38 5 1 1 45 2007 29 8 5 1 43 2008 19 8 2 2009 24 3 5 2010 14 4 13 PUUMALA VIRUS The number of Puumala virus cases reported in 2010 was 1,434, some 500 cases fewer than in 2009 and less than half of the 3,200 cases in the peak year of 2008. In each of the previous peak years, 2002 and 2005, there were about 2,500 cases. The number of cases varies, depending on the virus reservoir, i.e. the size of the bank vole population. The variation usually follows a three-year cycle such that two abundant years are followed by a quieter year. The patients’ age and gender distribution was the same as before. Of the patients, 60% were men, and most patients were of working age. There were 74 (5%) under 20 years of age. This time, the incidence was highest in the Kainuu hospital district (96/100,000 population) and in the Etelä-Savo hospital district (93/100,000 population) (Figure 16). TICK-BORNE ENCEPHALITIS (TBE) After the turn of the millennium, between 16 and 42 cases of TBE have been reported in Finland annually. In 2010, 44 TBE antibody findings were reported to the NIDR, and 38 patients had symptoms consistent with the disease. The TBE season in 2010 was from June to October, peaking in August and September. The patients were aged 5 to 85; one patient died of the disease. The patients included 10 people from Åland, 27 from elsewhere in Finland and one Swedish national who contracted the disease on Åland. In order to identify the place of acquisition, the National Institute for Health and Welfare interviewed 34 Report 39/2011 National Institute for Health and Welfare 2 29 1 1 33 3 35 patients who had been diagnosed with TBE in 2010 and/or studied their patient records. The results show that in 13 of the cases (34%) the patient contracted the infection on Åland, followed by the Imatra/Lappeenranta area (4), the Maalahti/Närpiö area (3), the Kokkola area (3), the Turku archipelago (3), the Kotka archipelago (2), Länsi-Uusimaa (1), Simo (1) and the Kuopio area (1). Three Finnish nationals were infected in the Baltic states. In two cases, the location of acquisition remained unclear (either in the Baltic states or in Finland, possibly on the south coast of the Gulf of Finland). Because of the systematic investigation of the place of acquisition, the Maalahti/Närpiö area (in 2007 and 2010), Varkaus (2008), Simo (2008, 2009 and 2010) and the Kotka archipelago (2010) have been identified as possible endemic TBE regions. If a patient falls ill with meningitis or encephalitis between May and October even though he or she has not noticed a tick bite, TBE should be suspected. Because new endemic TBE regions may continue to emerge, it is a good idea to consider the possibility of TBE infection even beyond currently known risk areas. TULAREMIA (FRANCISELLA TULARENSIS) The annual incidence of tularemia varies between 0.5 and 18/100,000 population. There are also notable variations in geographical incidence; epidemics tend to be local. In 2010, 91 laboratory-confirmed cases of tularemia were reported (1.7/100,000). The North- Infectious Diseases in Finland 2010 Puumala virus Cases/100,000 population 0–25/100,000 26–50/100,000 51–75/100,000 76–100/100,000 Figure 16. Cases of Puumala virus by hospital district, 2010 (no. of cases per 100,000 population). ern Bothnia hospital district had the highest number of cases (26). As in previous years, the incidence relative to population was highest in the Southern Bothnia, Northern Bothnia and Central Finland hospital districts, being 7.6/100,000, 6.6/100,000 and 5.1/100,000, respectively. The age and gender distribution of the patients also did not differ markedly from that of previous years. Most of the patients were in the age group 40 to 54; 54 of the patients (59%) were men. As is typical, the majority of the cases were diagnosed in August and September. POGOSTA DISEASE (SINDBIS VIRUS) Wild rodents are considered to be the animal reservoir for tularemia bacteria; the most common means of transmission to humans is by mosquito bite. Francisella tularensis may also be contracted from the bite of other kinds of invertebrate, or it can be transmitted in aerosol form, through contaminated water or food, or through direct contact with an infected animal. Sindbis virus is assumed to be transmitted mainly by insect bites. Rainfall about a month before the appearance of infections has been found to be a significant factor in incidence. Epidemics may be linked to local ecological factors and the cyclical variation of available animal reservoirs (forest game birds) or vectors. Cases of Pogosta disease tend to cluster in the In 2010, 57 cases were reported. The incidence was highest in the Central Finland, Southern Bothnia and Northern Karelia hospital districts (2.6/100,000, 2.5/100,000 and 1.8/100,000, respectively). The patients were 28 to 82 years old (median: 53 years), and 32 of them (56%) were women. The majority of the cases, 49 (86%), were diagnosed between July and September. Report 39/2011 National Institute for Health and Welfare 35 Infectious Diseases in Finland 2010 period from late July to September. The disease has an incubation period of less than a week and raises a fever, possibly with a rash and chronic symptoms (arthritic symptoms, for instance) that may persist for years. Pogosta disease has followed a regular sevenyear cycle since 1974 except for 2009. The epidemic peaked in 1981, 1995 and 2002; in 2009, however, only 106 cases were found (2/100,000). BORRELIA (LYME DISEASE) In 2010, the number of borrelia cases reported was 1,442, which is about the same as in the recordbreaking year 2009. The incidence in the whole country was 27/100,000 on average, but there was significant regional variation (Figure 17). Once again, the incidence was highest in the province of Åland (1,320/100,000), accounting for one in four of all diagnosed borrelia infections in Finland, 366 cases. As in previous years, the frequency of borrelia was highest in the autumn, from August to November. The majority of the patients (75%) were aged over 45; 54% of the patients were women. MALARIA AND OTHER TRAVELRELATED INFECTIONS Malaria Malaria was diagnosed in 33 patients in Finland in 2010. There were 22 cases of Plasmodium falciparum, 8 cases of P. vivax, 2 cases of P. ovale and one case of P. malariae. One patient had a relapse of vivax malaria. The majority of infections (26 cases, 79%) Borreliosis Cases/100,000 population 0–5/100,000 6–10/100,000 11–15/100,000 16–20/100,000 > 20/100,000 Figure 17. Borreliosis cases by hospital district, 2010 (no. of cases/100,000). 36 Report 39/2011 National Institute for Health and Welfare Infectious Diseases in Finland 2010 were acquired in Africa: 23 were acquired in western Africa and 3 in eastern or southern Africa. Of the rest, 4 came from the Indian subcontinent, 2 from Southeast Asia and one from the Caribbean. Five of the patients were native Finns who had taken a trip of less than six months to a malaria region, and four were Finns residing in a malaria region. Ten of the patients were immigrants who came from a malaria region and had returned to visit their home region; six were refugees who fell ill immediately after arriving in Finland. Eight were visitors to Finland. The number of malaria cases and the risk groups remained approximately the same as in previous years. None of the patients who fell ill with falciparum malaria had used the appropriate prophylaxis. Dengue fever Dengue fever cases have been on the increase in recent years. In 2010, laboratories reported 50 findings, when in 2009 the figure was 35. Rabies Doctors are required to report cases where risk assessment has led to the start of rabies vaccination treatment after exposure. In 2010, 46 suspected cases of rabies were reported to the NIDR. There were 21 patients who had been exposed during a trip abroad, 9 of them in Thailand. Some had been exposed in Russia, India and Turkey, and there were some additional isolated cases. In most cases, exposure consisted of dog bites. Other infections A significant percentage of the following infections are travel-related; the data on country of acquisition and routes of transmission are discussed separately for each of the following in their respective sections: Legionella p. 8, salmonella p. 12, campylobacter p. 14, shigella p. 15, EHEC p. 15, hepatitis A p. 20, hepatitis B p. 20, gonorrhoea p. 23, syphilis p. 24, HIV and AIDS p. 24, carbapenem-resistent gramnegative bacilli p. 29, MMR-diseases p. 33. Table 11. Malaria cases in Finland in 2010 by country of acquisition. Continent Country Asia India 4 Cambodia 2 Africa America Total Cases Total 6 Angola 1 Gambia 2 Ghana 6 Guinea 1 Cameroon 3 Liberia 1 Morocco 1 Nigeria 4 Ivory Coast 1 Sierra Leone 3 Sudan 1 Swaziland 1 Uganda 1 Total 26 Haiti 1 Total 1 33 Report 39/2011 National Institute for Health and Welfare 37 Infectious Diseases in Finland 2010 BLOOD AND CSF FINDINGS IN CHILDREN Blood culture findings in children The number of blood culture positive cases in children under 15 reported in 2010 was 659, roughly the same as in recent years (average between 2000 and 2009 was 617, variation 530 to 689). Just over half of the findings (321 out of 659) were in babies under 12 months old. Among infants, Staphylococcus epidermidis and other coagulase-negative staphylococci caused over 30% of blood culture positive infections. Though these bacteria belong to normal skin flora, they typically cause late-onset sepsis in newborn babies in intensive care. The second most common cause (17% of the findings) was Streptococcus agalactiae (Group B streptococcus, GBS). It is typically contracted from the mother’s birth canal during labour and causes an infection (early-onset sepsis) in the newborn baby during its first days of life. Other common causes of infection were Escherichia coli (14% of the findings), Staphylococcus aureus (7%), Enterococcus faecalis (6%) and Streptococcus pneumoniae (6%), as expected. S. pneumoniae (28%) and coagulase-negative staphylococcus (17%) were the most common findings in children aged 1 to 14 accounting for half of the reported cases in this age group. These were followed by S. aureus (13%) and the Streptococcus viridans group (11%). 38 Report 39/2011 National Institute for Health and Welfare CSF findings in children The number of bacterial and fungal findings related to children’s central nervous system infections remained at the same level as in the preceding years, as did the distribution of pathogens. The number of cases reported in 2010 was 30 (annual average from 2000 to 2009 was 36, variation 15 to 64). A majority of the findings (19 out of 30) were in babies under 12 months old. The most common findings in the age group of under 12 months were S. agalactiae, pneumococci and S. epidemidis (Table 14); in the age group 1 to 14, the most common findings were meningococci, pneumococci and S. aureus. GBS in newborns Between 1995 and 2010, an average of 35 cases per year of early-onset GBS in newborns (diagnosed from blood and/or CSF under the age of 7 days) were reported; the variation was 28 to 57 cases per year, and the incidence was 0.5 to 1.0 per 1,000 live births. There were 34 cases in 2010 (0.6 cases per 1,000 live births). The average figure for late-onset GBS between 1995 and 2010 was 16 cases per year; the variation was 6 to 24 cases per year, and the incidence was 0.1 to 0.4 per 1,000 live births. There were 22 cases in 2010 (0.4 cases per 1,000 live births). Infectious Diseases in Finland 2010 Table 12. Blood culture findings in infants (under 12 months), 2000–2010 (no. of cases). 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Staphylococcus, other coagulase-negative 27 23 36 20 36 31 42 39 33 43 32 Staphylococcus epidermidis 49 76 76 61 110 98 100 92 87 64 71 Streptococcus agalactiae 38 41 46 37 45 73 55 51 49 51 54 Escherichia coli 43 39 40 39 37 41 44 42 38 38 45 Streptococcus pneumoniae 26 19 17 25 28 26 28 21 26 25 19 S. aureus 17 17 24 21 32 32 37 25 23 22 24 Enterococcus faecalis 4 6 11 11 9 15 22 8 5 10 20 Streptococcus viridans group 6 10 8 13 15 12 10 9 8 9 17 Klebsiella species 9 8 7 8 9 9 8 6 8 9 3 Neisseria meningitidis 8 3 2 2 5 3 2 3 3 5 4 Streptococcus pyogenes 1 2 1 1 3 3 2 4 2 Enterobacter species 6 6 6 6 5 8 6 3 3 Streptococcus, other beta-haemolytic 1 1 1 2 3 2 Haemophilus influenzae 2 3 2 1 2 1 2 2 1 Enterococcus faecium 4 1 2 2 3 2 3 1 2 2 Streptococcus bovis group 1 1 1 1 1 Enterococcus, other or unidentified 3 13 1 2 1 Serratia species 3 5 2 4 Acinetobacter species 1 4 3 1 Listeria monocytogenes 1 1 Other bacteria 18 14 19 15 17 Bacteria, total 265 269 306 270 Candida albicans 3 3 10 2 Other candida species 9 8 8 2 2 2 3 4 1 2 3 2 1 1 3 2 1 1 2 10 14 19 17 12 13 364 359 387 333 313 309 319 3 4 4 2 3 1 2 1 1 1 2 1 1 Other fungi Fungi, total 1 1 12 11 18 4 3 5 4 4 4 Report 39/2011 National Institute for Health and Welfare 39 Infectious Diseases in Finland 2010 Table 13. Blood culture findings in children (aged 1 to 14), 2000–2010 (no. of cases). 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Streptococcus pneumoniae 72 76 92 94 88 101 99 115 87 92 94 Staphylococcus, other coagulase-negative 15 18 14 16 9 13 8 18 13 17 21 S. aureus 42 35 58 47 58 41 37 42 40 36 43 Staphylococcus epidermidis 48 26 40 30 25 41 40 33 22 31 37 Streptococcus viridans group 18 23 13 13 18 24 24 23 21 25 36 Escherichia coli 20 5 13 13 15 10 16 12 14 12 15 Streptococcus pyogenes 9 9 10 12 4 9 13 11 11 6 Enterococcus faecium 2 2 4 1 2 2 3 4 2 7 7 Other gram-positive cocci 6 6 4 2 8 7 9 6 4 6 11 2 4 2 2 4 2 6 6 4 6 5 8 2 1 4 1 2 2 4 1 1 6 3 3 1 2 4 3 2 2 1 2 3 3 3 6 3 2 1 3 7 Enterococcus faecalis Acinetobacter species 5 Enterobacter species 2 Haemophilus influenzae 2 2 1 5 Pseudomonas aeruginosa 6 7 4 6 Pseudomonas, other than aeruginosa 1 3 1 1 Klebsiella species 2 2 6 4 5 10 3 6 Streptococcus, other beta-haemolytic 1 1 3 2 2 4 1 Neisseria meningitidis 9 9 6 2 7 5 3 1 2 1 Serratia species 1 1 1 3 5 2 4 2 2 4 6 1 Other bacteria 36 18 27 27 25 38 26 39 32 17 34 Bacteria, total 296 249 309 290 270 317 293 331 271 278 336 Candida albicans 4 1 2 1 1 1 Other candida species 1 1 Other fungi Fungi, total 40 8 3 5 Report 39/2011 National Institute for Health and Welfare 1 1 2 3 3 1 1 2 2 3 2 1 5 4 2 1 3 0 2 Infectious Diseases in Finland 2010 Table 14. Cerebrospinal fluid culture findings in infants (under 12 months), 2000–2010 (no. of cases). 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 4 2 5 1 10 7 7 6 3 6 8 Staphylococcus, other coagulase-negative 5 1 2 1 4 1 Streptococcus pneumoniae 3 6 8 3 4 3 2 3 3 2 1 1 2 2 1 3 3 3 3 3 2 1 2 2 1 2 4 1 2 1 2 1 Streptococcus agalactiae S. aureus 1 Staphylococcus epidermidis Neisseria meningitidis 4 3 Streptococcus viridans group 1 1 Escherichia coli 3 1 1 2 2 2 1 1 Streptococcus pyogenes 1 2 1 Haemophilus influenzae 1 Klebsiella species 1 1 Enterococcus faecalis 1 1 1 1 1 1 2 Enterococcus faecium 1 1 Pseudomonas, other than aeruginosa 1 1 3 1 3 22 22 37 Other Haemophilus species Other bacteria Bacteria, total 9 9 16 2 2 19 19 15 Candida albicans 1 2 22 19 1 Other candida species Other fungi Fungi, total 0 0 0 0 0 0 0 0 0 1 0 Report 39/2011 National Institute for Health and Welfare 41 Infectious Diseases in Finland 2010 Table 15. Cerebrospinal fluid culture findings in children (aged 1 to 14), 2000–2010 (no. of cases). 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 Streptococcus pneumoniae 2 10 2 1 5 5 2 4 2 Staphylococcus, other coagulase-negative 3 2 2 2 1 2 2 7 1 4 2 7 4 4 5 1 1 S. aureus 2001 1 Staphylococcus epidermidis Neisseria meningitidis 5 4 Streptococcus pyogenes 7 2 3 3 2 1 5 2 1 5 3 2 3 1 Streptococcus viridans group Enterococcus faecalis 1 1 1 Enterococcus faecium 1 2 1 1 1 Enterococcus, other or unidentified Escherichia coli 1 1 Klebsiella species 1 Other bacteria 1 2 8 4 2 7 3 Bacteria, total 10 6 30 25 19 18 18 0 0 1 Candida albicans 8 5 2 13 21 17 11 0 0 0 0 1 Other candida species Other fungi Fungi, total 42 0 Report 39/2011 National Institute for Health and Welfare 0 0 0 1 Infectious Diseases in Finland 2010 BLOOD AND CSF FINDINGS IN ADULTS Blood culture findings in adults The total number of blood culture findings in adults has grown steadily and was nearly 11,000 in 2010 (2009: 10,226). Gram-positive bacteria were more common in the working-age population (aged 15 to 64) and gram-negative bacteria among those aged 65 or more. Anaerobic bacteria constituted less than 4% and fungi about 1% of all blood culture positive findings among adults. In the working-age population, the most common bacterial finding was Escherichia coli, constituting about 20% of all cases (Table 16). The next most common findings were Staphylococcus aureus (14%), coagulase-negative staphylococci (10%), Streptococcus pneumoniae (10%) and Klebsiella species (5%). E. coli was also the most common blood culture finding among patients aged 65 years or more, accounting for a third of all findings (Table 17). The next most common findings were Staphylococcus aureus (11%), coagulase-negative staphylococci (7%), Klebsiella species (7%) and Streptococcus pneumoniae (4%). CSF findings in adults There were 116 reported cases of microbial findings in CSF in adults in 2010; the annual average for the period 2000–2009 was 147, variation 32 to 193. Just under one third of the cases (36 out of 116) involved patients over 65 years old. Coagulase-negative staphylococcus was reported in about a quarter of the cases in working-age patients (Table19). The most common actual pathogens were pneumococcus (19%), S. aureus (15%) and meningococcus (8%). In patients aged 65 years or older, coagulase-negative staphylococcus accounted for 17% of the findings (Table 20). The most commonly reported actual pathogens were pneumococcus (17%), Listeria monocytogenes (17%) and S. aureus (14%). Group A streptococcus The prevailing emm types of Group A streptococcus (Streptococcus pyogenes) have given way in part to new, less known types, but the emm 1 type (previously T1M1) that caused severe illnesses in the past has also increased in prevalence. The most common emm types of the preceding years (emm1 and emm28) still prevail; the percentage of the emm84 type clearly decreased in 2008. A new type, emm119.1, has emerged. It was the fourth most common type, at 8% (Table 18, p. 49). Report 39/2011 National Institute for Health and Welfare 43 Infectious Diseases in Finland 2010 Table 16. Blood culture findings in patients aged 15 to 64, 2000–2010 (no. of cases). 44 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Escherichia coli 533 613 580 645 707 780 798 837 871 885 926 S. aureus 393 437 458 447 486 457 564 544 526 539 578 Staphylococcus, other coagulase-negative 128 108 143 114 126 113 120 141 152 137 138 Streptococcus pneumoniae 312 343 333 406 388 377 347 353 479 441 413 Staphylococcus epidermidis 274 298 301 286 294 286 281 265 279 313 261 Klebsiella species 115 114 134 121 159 184 145 159 198 187 207 Streptococcus viridans group 119 118 105 126 141 141 130 118 140 144 150 Streptococcus pyogenes 84 60 93 78 93 76 105 133 157 117 113 Streptococcus, other beta-haemolytic 59 66 78 79 102 96 127 117 113 113 131 Enterococcus faecalis 67 95 99 84 80 100 83 105 83 107 86 Streptococcus agalactiae 63 76 78 68 64 99 76 83 96 95 110 Enterococcus faecium 39 61 53 51 45 66 69 81 91 89 89 Enterobacter species 75 92 53 60 62 49 77 70 69 82 98 Pseudomonas aeruginosa 79 72 73 85 58 88 62 72 74 78 91 Bacteroides fragilis group 69 64 61 59 67 83 85 82 109 68 110 Streptococcus milleri group 48 46 48 48 48 54 62 64 72 57 68 Other gram-positive bacilli 18 14 20 30 33 32 28 18 31 40 39 Citrobacter species 19 18 14 10 21 15 28 19 23 29 31 Salmonella, other than Typhi 21 37 12 22 36 30 51 59 48 27 43 Fusobacterium species 17 26 15 21 32 31 19 31 31 27 36 Serratia species 8 10 12 14 10 16 18 19 24 27 20 Peptostreptococcus and Peptococcus 15 20 22 23 15 21 18 11 12 27 15 Other gram-negative bacilli 3 2 16 13 10 21 23 18 22 24 24 Clostridium, other than perfringens 17 9 7 9 7 19 14 11 13 22 11 Bacillus 23 20 18 22 15 18 22 24 25 21 32 Haemophilus influenzae 14 14 9 14 12 13 9 26 18 19 19 Proteus mirabilis 18 20 15 11 15 12 18 14 14 18 26 Acinetobacter species 18 9 13 10 16 16 10 21 13 18 14 Other gram-positive cocci 21 19 24 19 22 26 24 25 26 17 11 Report 39/2011 National Institute for Health and Welfare Infectious Diseases in Finland 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Clostridium perfringens 6 8 6 9 6 16 11 12 10 16 16 Enterococcus, other or unidentified 6 9 14 11 10 12 6 4 8 14 13 Prevotella species 6 11 4 11 11 15 11 8 13 13 15 Neisseria meningitidis 13 19 20 18 18 16 20 21 9 13 14 Corynebacterium species 28 19 23 9 12 12 9 8 8 13 11 Stenotrophomonas maltophilia 11 15 14 6 12 12 7 5 15 12 12 Capnocytophaga canimorsus 3 6 6 6 6 8 8 8 8 11 11 Campylobacter species 10 14 7 10 13 5 3 8 7 11 10 Bacteroides, other than fragilis group 2 6 5 6 2 4 3 5 11 2 Listeria monocytogenes 9 7 9 12 7 10 10 9 8 9 15 Propionibacterium species 20 19 8 11 6 9 7 5 3 9 6 Streptococcus, unidentified 6 4 14 5 9 6 8 8 14 8 5 Morganella morganii 7 4 3 4 4 3 8 7 14 8 6 Clostridium, unidentified 7 7 5 5 5 10 11 7 11 7 11 Pseudomonas, other than aeruginosa 3 2 3 4 5 4 4 9 7 7 Other gram-negative cocci 1 1 2 2 4 4 4 5 7 6 Veillonella species 4 4 2 3 1 6 3 5 3 7 5 Hafnia alvei 4 1 1 5 4 3 1 3 6 2 Streptococcus bovis group 4 3 2 2 3 8 5 7 1 6 7 Proteus vulgaris 1 3 3 4 3 7 3 2 3 2 Other enterobacteriaceae species 1 3 4 1 1 2 5 1 3 3 Salmonella Typhi 1 1 3 4 3 3 4 1 3 9 17 12 12 5 8 6 3 2 2 2 2 2 1 2 2 2 1 5 3 1 5 1 1 Staphylococcus, unidentified 11 15 Mycobacterium avium 2 3 Other gram-negative anaerobes 3 Yersinia enterocolitica 1 1 4 1 2 1 Other Haemophilus species 1 8 4 1 Mycobacterium, other than avium 1 1 1 4 Yersinia pseudotuberculosis 1 2 2 1 5 1 6 3 3 3 1 3 4 1 2 1 Report 39/2011 National Institute for Health and Welfare 45 Infectious Diseases in Finland 2010 2000 2001 2 1 16 10 Bacteria, total 2855 3090 3063 3138 3333 3504 3577 3686 Candida albicans 41 44 29 43 45 42 54 Other candida species 15 27 23 36 24 22 2 1 2 54 80 71 Other non-specified bacteria 2002 2003 2004 2005 2006 2007 2008 2009 2010 3980 3971 4090 55 55 55 57 24 27 43 30 38 1 2 2 4 5 2 65 80 84 102 90 97 1 Mycobacterium, unidentified Other gram-negative bacteria Other fungi Fungi, total 46 56 Report 39/2011 National Institute for Health and Welfare 71 Infectious Diseases in Finland 2010 Table 17. Blood culture findings in patients aged 65 or over, 2000-2010 (no. of cases). 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Escherichia coli 1033 1179 1213 1314 1466 1625 1706 1760 1890 2056 2223 S. aureus 398 398 449 466 483 483 601 568 672 691 725 Klebsiella species 201 241 230 253 341 339 326 338 420 462 466 Staphylococcus, other coagulase-negative 121 108 139 113 114 118 129 139 165 155 142 Streptococcus pneumoniae 189 216 200 241 239 229 270 294 326 294 298 Staphylococcus epidermidis 228 253 224 231 254 284 265 275 299 270 324 Enterococcus faecalis 144 142 149 146 192 183 202 220 217 222 228 Streptococcus, other beta-haemolytic 88 105 100 123 135 140 174 171 176 220 251 Pseudomonas aeruginosa 119 132 148 148 139 151 154 188 191 184 217 Enterococcus faecium 61 61 48 76 97 74 108 132 126 175 180 Bacteroides fragilis group 96 104 96 118 120 135 119 135 146 164 178 Streptococcus viridans group 74 93 83 103 103 106 110 115 140 135 132 Enterobacter species 79 97 87 97 92 115 95 105 131 128 156 Streptococcus agalactiae 53 61 49 62 76 84 81 77 94 104 126 Proteus mirabilis 61 51 57 62 80 57 68 93 99 102 106 Streptococcus milleri group 42 30 28 43 45 50 67 54 53 62 59 Streptococcus pyogenes 21 28 46 28 30 34 48 58 51 62 52 Citrobacter species 26 39 40 44 43 42 42 35 65 59 76 Clostridium perfringens 23 31 26 27 32 29 36 39 34 49 40 Other gram-positive cocci 11 9 13 15 13 13 22 22 34 38 22 Serratia species 15 30 15 28 18 33 27 33 50 37 59 Other gram-positive bacilli 22 14 17 28 34 36 33 27 39 36 45 Peptostreptococcus and Peptococcus 15 9 14 20 13 17 22 25 14 29 36 Streptococcus bovis group 9 10 7 9 20 12 17 17 15 25 12 Clostridium, other than perfringens 17 17 13 7 12 22 19 15 22 24 25 Enterococcus, other or unidentified 7 22 19 21 17 17 19 16 24 22 26 Haemophilus influenzae 17 27 15 13 13 28 21 24 21 22 19 5 10 15 24 18 17 21 21 20 11 19 18 20 26 26 26 20 44 Other gram-negative bacilli Listeria monocytogenes 7 15 Report 39/2011 National Institute for Health and Welfare 47 Infectious Diseases in Finland 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Morganella morganii 12 9 13 10 14 21 14 26 11 18 28 Acinetobacter species 13 18 17 8 13 10 18 11 12 16 16 Prevotella species 5 8 11 4 11 10 10 8 11 15 13 Clostridium, unidentified 7 9 8 11 14 7 11 18 6 15 18 Bacteroides, other than fragilis group 7 5 3 5 8 4 3 5 8 13 8 Corynebacterium species 21 16 15 7 11 14 11 13 12 12 17 Bacillus 13 17 11 10 10 10 17 9 11 12 7 Pseudomonas, other than aeruginosa 9 3 6 6 3 7 10 11 11 11 11 1 1 2 5 1 3 8 9 5 Other gram-negative cocci Propionibacterium species 19 12 15 4 8 13 9 4 5 9 10 Fusobacterium species 6 6 16 7 13 10 9 15 10 8 17 Other enterobacteriaceae species 1 1 3 4 4 3 1 4 8 8 Hafnia alvei 3 7 1 1 4 4 3 6 8 7 7 Salmonella, other than Typhi 5 4 7 5 6 15 11 8 19 6 8 Streptococcus, unidentified 8 7 12 9 12 10 15 7 12 6 16 Neisseria meningitidis 5 4 4 4 3 2 5 2 6 6 6 Campylobacter species 2 3 3 1 5 3 5 3 5 6 3 Stenotrophomonas maltophilia 4 8 3 6 10 6 10 8 3 6 7 Veillonella species 3 1 1 7 2 6 9 5 4 Staphylococcus, unidentified 23 27 16 21 21 6 4 5 6 5 6 Proteus vulgaris 4 8 7 8 7 9 9 9 4 4 8 2 1 1 2 2 1 1 1 1 1 1 1 4 2 3 2 2 Other gram-negative anaerobes 3 1 3 1 1 2 4 1 2 Other Haemophilus species 2 1 3 2 2 1 1 1 1 1 3 1 1 1 1 1 1 2 3 5 1 Yersinia pseudotuberculosis Capnocytophaga canimorsus 3 Yersinia enterocolitica 3 1 Mycobacterium, other than avium 2 2 Mycobacterium avium Salmonella Typhi 48 Report 39/2011 National Institute for Health and Welfare 1 1 1 1 3 1 1 4 Infectious Diseases in Finland 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Other non-specified bacteria 2 Other gram-negative bacteria 14 8 Bacteria, total 3371 3709 3723 4007 4443 4686 5019 5204 5752 6073 6520 Candida albicans 41 48 39 63 51 39 54 56 66 49 93 Other candida species 27 22 31 47 27 25 22 27 25 43 35 92 128 Other fungi 1 1 Fungi, total 68 3 71 70 3 113 78 2 67 76 83 93 Table 18. Group A Streptococcus blood findings by emm-type, 2006−2010 (no. of cases and %). Cases notified to NIDR Strains examined emm1 emm28 emm84 emm89 Other NT 2006 163 25 (15 %) 33 (20 %) 24 (15 %) 11 (7 %) 59 (36 %) 11 (7 %) 2007 205 58 (28 %) 26 (13 %) 32 (16 %) 12 (6 %) 72 (35 %) 5 (2 %) 2008 225 52 (23 %) 47 (21 %) 9 (4 %) 10 (4 %) 102 (45 %) 5 (2 %) 2009 191 25 (13 %) 56 (29 %) 4 (2 %) 29 (15 %) 74 (39 %) 3 (2 %) 2010 167 22 (13 %) 37 (22 %) 4 (2 %) 26 (16 %) 77 (46 %) 1 (<1 %) Report 39/2011 National Institute for Health and Welfare 49 Infectious Diseases in Finland 2010 Table 19. Cerebrospinal fluid culture findings in patients aged 15 to 64, 2000–2010 (no. of cases). 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 15 7 16 14 12 7 14 10 8 19 26 21 15 17 14 26 19 15 27 21 24 34 32 17 27 18 11 6 10 17 10 9 16 13 13 12 19 15 11 15 20 16 4 9 6 Pseudomonas aeruginosa 5 4 2 4 6 3 4 5 3 Pseudomonas, other than aeruginosa 6 6 11 5 5 5 4 4 7 7 4 3 3 4 1 3 5 2 2 9 3 1 Staphylococcus, other coagulase-negative Streptococcus pneumoniae 1 4 Staphylococcus epidermidis S. aureus 11 Neisseria meningitidis 9 Escherichia coli 8 2 3 Enterobacter species Enterococcus faecalis 1 2 3 5 3 4 5 4 3 4 Other non-specified bacteria 1 1 1 4 7 5 3 3 2 Acinetobacter species 2 1 1 3 3 5 2 3 2 1 1 3 2 1 4 2 1 Streptococcus pyogenes 1 1 2 2 1 Streptococcus viridans group 6 2 1 2 1 Klebsiella species 3 2 Listeria monocytogenes 3 2 1 1 Other gram-positive cocci 1 Streptococcus, other beta-haemolytic 2 1 2 1 Haemophilus influenzae 1 3 Pseudomonas, other 1 Other gram-negative cocci 1 Enterococcus faecium 1 Corynebacterium species 1 Staphylococcus, unidentified 3 Peptostreptococcus and Peptococcus 4 7 2 1 2 2 2 1 1 2 1 1 1 2 1 2 3 1 1 1 1 1 1 1 1 2 1 1 2 1 1 1 1 1 1 1 1 1 1 2 1 Capnocytophaga canimorsus 50 1 Bacillus 5 Streptococcus agalactiae 1 Mycobacterium, other than avium 1 2 Report 39/2011 National Institute for Health and Welfare 2 3 2 1 6 4 3 1 5 2 1 2 2 Infectious Diseases in Finland 2010 2000 2001 Salmonella, other than Typhi 1 Enterococcus, other or unidentified 1 2002 2003 2004 2005 2006 2007 1 2008 2009 2010 2 1 1 1 Streptococcus milleri group 1 1 Serratia species 2 1 1 3 Citrobacter species 1 1 2 1 Stenotrophomonas maltophilia 1 1 1 Other Haemophilus species 1 Other gram-negative bacilli 2 1 1 Streptococcus, unidentified Other gram-positive bacilli 1 Morganella morganii 1 1 Campylobacter species 1 Fusobacterium species Prevotella species Bacteria, total 1 31 23 136 111 127 139 Candida albicans 1 1 2 1 Other candida species 1 4 1 146 139 114 79 1 3 Other fungi Fungi, total 124 4 1 1 1 0 0 2 1 6 2 3 6 1 0 1 Report 39/2011 National Institute for Health and Welfare 51 Infectious Diseases in Finland 2010 Table 20. Cerebrospinal fluid culture findings in patients aged 65 or over, 2000–2010 (no. of cases). 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 Streptococcus pneumoniae 4 5 4 9 10 4 7 10 6 Staphylococcus, other coagulase-negative 5 4 5 5 3 2 3 3 4 7 5 6 10 9 12 10 6 2 2 7 7 5 3 2 3 6 5 1 1 3 1 3 2 2 2 6 2 2 1 1 1 1 1 1 1 1 1 1 1 Staphylococcus epidermidis S. aureus 2001 1 2 Streptococcus viridans group 1 Listeria monocytogenes 1 2 Pseudomonas, other than aeruginosa 1 4 1 4 2 4 1 Haemophilus influenzae 2 1 Mycobacterium, other than avium 2 1 1 4 1 3 Escherichia coli 1 1 1 2 2 1 2 2 1 Proteus mirabilis Klebsiella species Enterococcus faecalis 1 1 1 Other non-specified bacteria Streptococcus agalactiae 2 1 3 1 4 2 2 2 3 1 1 2 2 1 4 1 1 1 Streptococcus, other beta-haemolytic 2 1 1 Streptococcus milleri group 1 Streptococcus bovis group 1 Enterococcus faecium 1 1 Bacteroides fragilis group 1 Pseudomonas aeruginosa 1 Staphylococcus, unidentified 1 Bacillus Neisseria meningitidis 52 1 1 2 1 1 3 1 1 1 Enterobacter species 2 Acinetobacter species 2 Streptococcus pyogenes 2 Streptococcus, unidentified 1 Enterococcus, other or unidentified 1 Report 39/2011 National Institute for Health and Welfare 1 1 2 1 1 1 1 1 1 2 1 1 1 1 Infectious Diseases in Finland 2010 2000 2001 2002 Peptostreptococcus and Peptococcus 2003 2004 2005 2006 2007 2008 2009 2010 1 Mycobacterium avium 1 Corynebacterium species 1 Other gram-positive bacilli 1 Serratia species 1 1 Proteus vulgaris 1 Morganella morganii Yersinia enterocolitica Other enterobacteriaceae species 1 Pseudomonas, other 1 Stenotrophomonas maltophilia 1 Other Haemophilus species Capnocytophaga canimorsus Bacteria, total 10 9 42 45 37 Candida albicans 47 42 32 1 Other candida species 2 1 37 45 36 1 2 2 Other fungi Fungi, total 0 0 2 0 1 1 2 0 1 2 0 Report 39/2011 National Institute for Health and Welfare 53 Infectious Diseases in Finland 2010 Table 21. Blood culture findings in all age groups, 2000–2010 (no. of cases). 54 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Escherichia coli 1629 1836 1846 2011 2225 2456 2564 2651 2813 2991 3209 S. aureus 850 887 989 981 1059 1013 1239 1179 1261 1288 1370 Staphylococcus, other coagulase-negative 291 257 332 263 285 275 299 337 363 352 333 Streptococcus pneumoniae 599 654 642 766 743 733 744 783 918 852 824 Staphylococcus epidermidis 599 653 641 608 683 709 686 665 687 678 693 Klebsiella species 327 365 377 386 514 542 482 509 631 660 680 Enterococcus faecalis 215 245 263 243 283 302 309 339 311 343 340 Streptococcus, other beta-haemolytic 149 172 179 206 241 238 306 289 289 338 386 Streptococcus viridans group 217 244 209 255 277 283 274 265 309 313 335 Enterococcus faecium 106 125 107 130 147 144 183 217 220 273 278 Pseudomonas aeruginosa 204 213 226 240 204 245 219 262 268 265 317 Streptococcus agalactiae 155 178 173 169 186 256 212 213 240 250 290 Bacteroides fragilis group 169 170 158 177 189 221 204 218 256 233 289 Enterobacter species 162 195 147 169 162 170 186 185 210 216 259 Streptococcus pyogenes 115 99 150 119 130 110 162 207 221 194 173 Streptococcus milleri group 93 77 78 91 93 107 132 118 127 121 129 Proteus mirabilis 79 71 72 73 97 69 87 109 113 120 132 Citrobacter species 50 60 56 55 64 59 71 56 90 90 109 Other gram-positive bacilli 42 31 42 64 70 75 62 47 70 80 90 Clostridium perfringens 29 39 33 37 38 46 48 53 44 66 57 Serratia species 26 40 33 44 32 50 49 56 78 65 82 Other gram-positive cocci 41 35 44 38 45 48 57 56 67 62 44 Peptostreptococcus and Peptococcus 33 31 36 43 28 38 40 36 26 56 52 Other gram-negative bacilli 3 2 26 28 27 47 42 38 47 47 47 Clostridium, other than perfringens 35 27 20 16 20 42 34 26 35 47 37 Haemophilus influenzae 35 46 25 34 26 45 32 53 44 46 42 Acinetobacter species 37 32 42 23 31 31 32 36 28 39 34 Bacillus 46 41 34 39 29 37 46 37 46 38 43 Enterococcus, other or unidentified 13 31 33 34 30 29 27 23 35 38 40 Report 39/2011 National Institute for Health and Welfare Infectious Diseases in Finland 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Fusobacterium species 27 33 34 28 46 43 31 51 46 36 54 Salmonella, other than Typhi 27 42 21 28 43 46 64 72 69 34 57 Streptococcus bovis group 14 13 10 12 24 21 23 24 16 33 19 Listeria monocytogenes 17 24 20 32 25 30 38 36 34 30 61 Prevotella species 11 19 15 15 23 25 21 16 25 28 28 Corynebacterium species 53 37 39 18 24 29 24 24 21 27 29 Morganella morganii 20 13 16 14 18 24 22 33 25 26 34 Neisseria meningitidis 35 35 34 30 28 28 32 29 22 24 30 Bacteroides, other than fragilis group 10 11 8 5 14 6 7 8 13 24 10 Stenotrophomonas maltophilia 17 25 18 14 25 19 18 18 22 22 23 Clostridium, unidentified 14 16 14 16 19 17 22 26 18 22 31 Pseudomonas, other than aeruginosa 13 8 10 11 8 12 10 16 20 21 18 Propionibacterium species 40 31 24 16 14 22 16 10 8 18 16 Other gram-negative cocci 1 1 5 2 8 12 10 12 18 17 18 Campylobacter species 14 18 10 11 18 8 8 11 12 17 13 Streptococcus, unidentified 14 12 27 14 21 16 24 16 26 15 22 Capnocytophaga canimorsus 6 7 7 7 7 9 12 10 11 13 13 Hafnia alvei 7 8 2 6 8 7 3 7 11 13 9 Veillonella species 7 4 2 4 2 13 7 11 12 12 10 Other enterobacteriaceae species 2 4 3 8 1 6 5 6 5 11 11 Staphylococcus, unidentified 36 43 40 38 40 15 12 16 10 7 8 Proteus vulgaris 6 11 7 11 11 12 16 12 6 7 10 1 2 5 5 6 3 6 1 3 9 4 3 3 3 2 1 1 1 3 3 7 2 5 3 2 8 7 2 7 3 2 2 2 2 2 2 2 1 3 Salmonella Typhi Yersinia pseudotuberculosis 1 Other gram-negative anaerobes Mycobacterium avium 2 3 1 1 Yersinia enterocolitica 3 2 1 3 1 2 1 1 Other Haemophilus species 1 8 6 3 8 9 6 4 5 Mycobacterium, other than avium 3 3 1 6 3 1 8 5 2 4 Report 39/2011 National Institute for Health and Welfare 55 Infectious Diseases in Finland 2010 2000 2001 2002 4 1 1 33 21 Bacteria, total 6787 7317 7401 7705 8410 8866 9276 9554 Candida albicans 89 96 80 109 99 86 113 Other candida species 52 57 62 85 52 48 1 3 6 2 154 145 200 153 Other non-specified bacteria 2003 2004 2005 2006 2007 2008 2009 2010 10316 10631 11265 113 126 105 154 48 58 70 73 73 4 4 4 6 5 2 138 165 175 202 183 229 1 Mycobacterium, unidentified Other gram-negative bacteria Other fungi Fungi, total 56 141 Report 39/2011 National Institute for Health and Welfare Infectious Diseases in Finland 2010 Table 22. Cerebrospinal fluid culture findings in all age groups, 2000–2010 (no. of cases). 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 28 14 25 22 15 9 21 15 12 4 28 47 35 28 33 27 38 35 26 1 44 30 37 49 44 32 43 28 16 9 22 28 16 12 21 21 24 20 Staphylococcus, other coagulase-negative Streptococcus pneumoniae 1 Staphylococcus epidermidis S. aureus 15 Neisseria meningitidis 18 16 27 22 20 22 29 23 9 13 12 Streptococcus agalactiae 8 5 6 2 12 7 8 11 5 7 11 Streptococcus viridans group 7 4 3 4 10 3 1 7 3 Other non-specified bacteria 4 1 1 9 10 7 9 6 7 1 10 7 13 6 7 5 6 6 8 4 5 3 4 8 8 4 5 6 4 Pseudomonas aeruginosa 5 4 3 4 7 3 6 5 3 Enterobacter species 3 6 5 2 3 9 4 2 Pseudomonas, other than aeruginosa Escherichia coli 4 Klebsiella species 3 2 3 3 3 3 2 1 5 4 1 Enterococcus faecalis 5 4 4 7 7 6 8 9 4 4 5 2 2 6 3 4 5 3 3 4 7 3 2 1 2 1 4 1 2 3 1 2 2 2 4 3 Acinetobacter species 6 2 2 4 5 6 2 3 Streptococcus pyogenes 4 1 2 3 Other gram-positive cocci 5 1 3 Enterococcus faecium 2 1 3 1 3 6 1 3 Corynebacterium species 2 1 2 Pseudomonas, other 1 1 2 1 Listeria monocytogenes Streptococcus, other beta-haemolytic Haemophilus influenzae Mycobacterium, other than avium 2 1 1 1 1 2 3 1 1 1 1 2 1 2 1 1 1 1 1 1 Streptococcus milleri group 1 1 Proteus mirabilis 1 1 1 1 Other gram-negative cocci Other gram-negative bacilli 1 1 1 Staphylococcus, unidentified 4 5 4 2 2 2 3 1 1 1 1 Report 39/2011 National Institute for Health and Welfare 57 Infectious Diseases in Finland 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 Streptococcus bovis group Peptostreptococcus and Peptococcus 3 1 2009 2010 1 1 1 Capnocytophaga canimorsus 1 Bacteroides fragilis group 1 Bacillus 8 Salmonella, other than Typhi 1 Enterococcus, other or unidentified 1 7 4 1 1 Stenotrophomonas maltophilia 1 1 2 3 1 3 1 1 2 2 1 2 1 1 2 1 Other Haemophilus species 1 Bacteroides, other than fragilis group 1 Streptococcus, unidentified 4 2 2 Serratia species Citrobacter species 3 1 1 1 Mycobacterium avium 1 Other gram-positive bacilli 1 1 1 Proteus vulgaris 1 Morganella morganii 1 Yersinia enterocolitica Other enterobacteriaceae species 1 Campylobacter species 1 Fusobacterium species Prevotella species Bacteria, total 1 60 47 230 203 220 220 Candida albicans 1 1 3 2 Other candida species 3 5 1 225 5 Other fungi Fungi, total 58 188 212 198 146 1 1 1 4 1 2 1 2 3 1 1 0 Report 39/2011 National Institute for Health and Welfare 0 4 1 8 3 5 6 Infectious Diseases in Finland 2010 Authors Respiratory infections Influenza A and B Niina Ikonen, Thedi Ziegler, Outi Lyytikäinen (National institute for health and welfare, THL) RSV Thedi Ziegler, Outi Lyytikäinen (THL) Legionella Teija T Korhonen, Outi Lyytikäinen, Sari Jaakola (THL) Whooping cough Teija T Korhonen, Qiushui He (THL) Adenovirus Thedi Ziegler, Outi Lyytikäinen (THL) Parainfluenza Thedi Ziegler, Outi Lyytikäinen (THL) Mycoplasma Mirja Puolakkainen (University of Helsinki) Chlamydial pneumonia Mirja Puolakkainen (University of Helsinki) Hepatitides Hepatitis A Markku Kuusi, Irja Davidkin (THL) Hepatitis B Henrikki Brummer-Korvenkontio, Kirsi Liitsola (THL) Hepatitis C Henrikki Brummer-Korvenkontio, Kirsi Liitsola (THL) Gastrointestinal infections Salmonella Ruska Rimhanen-Finne, Anja Siitonen, Taru Lienemann, Aino Kyyhkynen (THL) Campylobacter Markku Kuusi, Ulla-Maija Nakari (THL) Yersinia Elisa Huovinen, Leila Sihvonen (THL) Shigella Markku Kuusi, Anja Siitonen (THL) EHEC Katri Jalava, Aino Kyyhkynen, Anja Siitonen (THL) Norovirus Merja Roivainen, Markku Kuusi (THL), Leena Maunula (University of Helsinki) Rotavirus Tuija Leino, Merja Roivainen (THL) Enterovirus Katri Jalava, Merja Roivainen, Outi Lyytikäinen (THL) Listeria Ruska Rimhanen-Finne, Ulla-Maija Nakari (THL) Clostridium difficile Outi Lyytikäinen (THL) , Anni Virolainen-Julkunen (Ministry of social affairs and health, STM) , Silja Mentula (THL) Food- and water-borne outbreaks Ruska Rimhanen-Finne, Markku Kuusi, Taru Lienemann, Aino Kyyhkynen, Anja Siitonen (THL) Antimicrobial resistance MRSA Outi Lyytikäinen , Saara Salmenlinna, Jaana Vuopio (THL) VRE Outi Lyytikäinen, Minna Kardén-Lilja , Jaana Vuopio (THL) ESBL Outi Lyytikäinen, Jari Jalava (THL) Invasive pneumococcal disease Outi Lyytikäinen, Jari Jalava, Antti Hakanen (THL) Sexually transmitted diseases Chlamydia Eija Hiltunen-Back (HUS) Gonorrhoea Eija Hiltunen-Back (HUS), Antti Hakanen (THL) Syphilis Eija Hiltunen-Back (HUS) HIV and AIDS Henrikki Brummer-Korvenkontio, Kirsi Liitsola (THL) Mycobacterial infections Tuberculosis Petri Ruutu, Merja Marjamäki (THL), Tuula Vasankari (Turku University Hospital and THL) Other infections Haemophilus Anni Virolainen-Julkunen (STM ), Maija Toropainen (THL) Meningococcus Anni Virolainen-Julkunen (STM), Maija Toropainen, Outi Lyytikäinen (THL) MMR diseases (measles, mumps, rubella) Irja Davidkin (THL) Puumala virus Teija T Korhonen (THL) Report 39/2011 National Institute for Health and Welfare 59 Infectious Diseases in Finland 2010 Tick-borne encephalitis (TBE) Teija T Korhonen (THL), Olli Vapalahti (HUS) Tularemia Heidi Rossow (THL) Pogosta disease Katri Jalava (THL) Borrelia Teija T Korhonen (THL) Malaria and other travel-related infections Heli Siikamäki (HUS), Eeva Pekkanen (THL) Blood and CSF findings in children Outi Lyytikäinen (THL) Blood and CSF findings in adults Outi Lyytikäinen, Tuula Siljander, Jaana Vuopio (THL) 60 Report 39/2011 National Institute for Health and Welfare Infectious Diseases in Finland 2010 Report 39/2011 National Institute for Health and Welfare 61 Infectious Diseases in Finland 2010 62 Report 39/2011 National Institute for Health and Welfare Infectious Diseases in Finland 2010 Report 39/2011 National Institute for Health and Welfare 63 Infectious Diseases in Finland 2010 64 Report 39/2011 National Institute for Health and Welfare