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REPORT
Sari Jaakola
Outi Lyytikäinen
Ruska Rimhanen-Finne
Saara Salmenlinna
Jaana Vuopio
Merja Roivainen
Hanna Nohynek
Jan-Erik Löflund
Markku Kuusi
Petri Ruutu
(eds.)
Sari Jaakola, Outi Lyytikäinen, Ruska Rimhanen-Finne,
Saara Salmenlinna, Jaana Vuopio, Merja Roivainen,
Hanna Nohynek, Jan-Erik Löflund, Markku Kuusi, Petri Ruutu (eds.)
Infectious Diseases in Finland 2012
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ISBN 978-952-245-893-3
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12 | 2013
12 | 2013
Infectious Diseases
in Finland 2012
Jaakola Sari, Lyytikäinen Outi, Rimhanen-Finne Ruska,
Salmenlinna Saara, Vuopio Jaana, Roivainen Merja, Nohynek Hanna,
Löflund Jan-Erik, Kuusi Markku, Ruutu Petri (eds.)
Infectious Diseases in Finland 2012
Report 12/2013
© Publisher
National Institute for Health and Welfare (THL)
Department of Infectious Disease Surveillance and Control
PO Box 30 (Mannerheimintie 166)
FI-00271 Helsinki, Finland
Tel. 029 524 6000
http://www.thl.fi/infektiotaudit
Editors: Sari Jaakola, Outi Lyytikäinen, Ruska Rimhanen-Finne, Saara Salmenlinna, Jaana Vuopio, Merja Roivainen, Hanna Nohynek, Jan-Erik Löflund, Markku Kuusi 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
Infectious Diseases in Finland 2012.
National Institute for Health and Welfare, Report 12/2013
ISBN (printed) 978-952-245-893-3
ISSN (printed) 1798-0070
ISBN (online) 978-952-245-894-0
ISSN (online) 1798-0089
http://urn.fi/URN: ISBN:978-952-245-894-0
Juvenes Print − Suomen yliopistopaino Oy
Tampere
Infectious Diseases in Finland 2012
Contents
Introduction • 5
Respiratory infections • 7
Influenza��������������������������������������������������������������������������������������������������������������������������������������������������� 7
RSV���������������������������������������������������������������������������������������������������������������������������������������������������������� 9
Legionella����������������������������������������������������������������������������������������������������������������������������������������������� 10
Whooping cough������������������������������������������������������������������������������������������������������������������������������������ 10
Adenovirus���������������������������������������������������������������������������������������������������������������������������������������������� 11
Parainfluenza������������������������������������������������������������������������������������������������������������������������������������������ 11
Mycoplasma pneumoniae����������������������������������������������������������������������������������������������������������������������� 12
Chlamydia pneumoniae�������������������������������������������������������������������������������������������������������������������������� 12
Gastrointestinal infections • 13
Salmonella���������������������������������������������������������������������������������������������������������������������������������������������� 13
Campylobacter��������������������������������������������������������������������������������������������������������������������������������������� 15
Yersinia��������������������������������������������������������������������������������������������������������������������������������������������������� 15
Shigella��������������������������������������������������������������������������������������������������������������������������������������������������� 16
Enterohaemorrhagic Escherichia coli (EHEC)������������������������������������������������������������������������������������������ 16
Norovirus������������������������������������������������������������������������������������������������������������������������������������������������ 16
Rotavirus������������������������������������������������������������������������������������������������������������������������������������������������ 17
Enterovirus��������������������������������������������������������������������������������������������������������������������������������������������� 17
Listeria���������������������������������������������������������������������������������������������������������������������������������������������������� 18
Clostridium difficile���������������������������������������������������������������������������������������������������������������������������������� 18
Food-borne epidemics����������������������������������������������������������������������������������������������������������������������������� 19
Hepatitides • 22
Hepatitis A��������������������������������������������������������������������������������������������������������������������������������������������� 22
Hepatitis B��������������������������������������������������������������������������������������������������������������������������������������������� 22
Hepatitis C��������������������������������������������������������������������������������������������������������������������������������������������� 22
Sexually transmitted diseases • 25
Chlamydia���������������������������������������������������������������������������������������������������������������������������������������������� 25
Gonorrhoea�������������������������������������������������������������������������������������������������������������������������������������������� 25
Syphilis��������������������������������������������������������������������������������������������������������������������������������������������������� 26
HIV and AIDS��������������������������������������������������������������������������������������������������������������������������������������� 26
Antimicrobial resistance • 28
MRSA���������������������������������������������������������������������������������������������������������������������������������������������������� 28
VRE������������������������������������������������������������������������������������������������������������������������������������������������������� 28
ESBL������������������������������������������������������������������������������������������������������������������������������������������������������ 29
Invasive pneumococcal disease���������������������������������������������������������������������������������������������������������������� 31
Tuberculosis • 34
Tuberculosis�������������������������������������������������������������������������������������������������������������������������������������������� 34
Other infections • 38
Haemophilus������������������������������������������������������������������������������������������������������������������������������������������ 38
Meningococcus��������������������������������������������������������������������������������������������������������������������������������������� 38
MMR diseases (measles, mumps, rubella)����������������������������������������������������������������������������������������������� 39
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Varicella virus������������������������������������������������������������������������������������������������������������������������������������������ 40
Puumala virus����������������������������������������������������������������������������������������������������������������������������������������� 41
Tick-borne encephalitis (TBE)���������������������������������������������������������������������������������������������������������������� 41
Tularemia������������������������������������������������������������������������������������������������������������������������������������������������ 42
Pogosta disease���������������������������������������������������������������������������������������������������������������������������������������� 42
Borrelia (Lyme disease)��������������������������������������������������������������������������������������������������������������������������� 42
Rabies����������������������������������������������������������������������������������������������������������������������������������������������������� 42
Malaria, dengue fever and other travel-related infections������������������������������������������������������������������������� 43
Blood and CFS findings in children�������������������������������������������������������������������������������������������������������� 45
Blood and CFS findings in adults����������������������������������������������������������������������������������������������������������� 52
Authors • 66
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Infectious Diseases in Finland 2012
Introduction
No significant changes occurred in national or international cooperation in the surveillance and prevention of infectious diseases in 2012. The ongoing
reform of the Communicable Diseases Act will enhance support for the surveillance and prevention of
infectious diseases.
In 2012, the International Health Regulations of the
World Health Organization (IHR 2005) having been
in force for five years, the WHO surveyed member
states to find out whether they had attained the core
preparedness for surveillance and prevention of infectious diseases required of member states in the
IHR. Finland considered in its response that it had
attained the required core preparedness, but a total of
110 countries applied to the WHO for a two-year extension to the implementation of the IHR. Finland’s
national pandemic preparedness plan was updated,
but it also requires continuous development because
of constant changes in threat scenarios and the operating environment.
Patient safety has become an increasingly important
focus area over the years. By extension, cooperation
among those involved with patient safety issues regarding healthcare-associated infections and beyond
has become more important than ever. The combating of antimicrobial resistance is also a patient safety
issue, as its aim is to ensure that patients with infections receive effective treatment.
The leveraging of data in the AvoHILMO system,
based on monitoring of the reasons for health care
visits in primary health care compiled and updated
on a daily basis, for the purpose of rapid detection
and surveillance of epidemics, is progressing: updated
data is already available from more than 100 health
care centres. What is vital for achieving high-quality
surveillance is to implement comprehensive encoding of reasons for health care visits as a part of routine
reception procedure. Monitoring of reasons for visits
and virological surveillance at sentinel sites at selected
health care centres help provide an earlier and more
representative picture of influenza epidemics and the
viruses that cause them. The system will be extended
to cover other epidemics such as diarrhoea.
EPIDEMIOLOGICAL OVERVIEW 2012
The dominant virus in the influenza epidemic of winter 2011–2012 was A(H3N2), which differed nota-
bly in structure from the virus included in the seasonal vaccine. The following influenza season, 2012–
2013, was launched by the B virus and began early,
in November and December 2012. The RSV winter
epidemic of 2011–2012 was more extensive than in
the previous year, persisting until April 2012. The
major mycoplasma epidemic that had begun in late
2010 continued, peaking for a second time in winter
2011–2012.
Several children were hospitalised in intensive care in
an EHEC outbreak transmitted through unpasteurised milk and animal contact. More cases of listeria
were recorded than in previous years; this was partly
due to an epidemic in which bacteria could be detected not only in severe cases but also in the faeces
of patients with diarrhoea and fever. The number of
cases of Clostridium difficile infection remained high,
but there was considerable regional variation in their
incidence. The number of norovirus infections and
outbreaks increased substantially in connection with
the emergence of a new variant of the virus. The annual number of rotavirus infections amounted to
only 10% of what it was before the introduction of
a rotavirus vaccine into the national vaccination programme in 2009. The five cryptosporidium outbreaks
recorded in various parts of the country are suspected
to have been transmitted through imported lettuce.
Fewer than ten cases of hepatitis A were reported during the year, a record low. The number of acute hepatitis B infections was also low compared to the situation
ten years ago; the patients in about half of the cases
reported were among foreign-borns. The incidence of
hepatitis C infections was highest in the age group 24
to 29; in about half of the cases, intravenous drug use
was mentioned as the source of transmission.
The annual number of gonorrhoea infections continued to grow, reaching a new record for the 2000s.
The annual number of new HIV infections has remained stable for the past five years, and no changes
were observed in the modes of transmission or gender
distribution.
There were fewer severe cases of MRSA confirmed by
blood culture than in the previous year, and the overall number of MRSA cases remained stable. By contrast, the number of cases of E. coli with reduced susceptibility to third-generation cephalosporin (ESBL)
confirmed by blood culture continued to grow. Of
the 11 cases of infections caused by strains of E. coli
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5
Infectious Diseases in Finland 2012
and K. pneumoniae producing carbapenemase, all except one were of foreign origin.
The number of severe cases of pneumococcal infection
continued to decline compared with the situation before the introduction of the vaccine, and almost completely disappeared in the age group of under 2. The
number of severe Haemophilus influenzae infections
increased sharply, but the number of those caused by
the type b serotype, which can be prevented by vaccination, did not increase. Severe group Y meningococcus infections were prevalent in older age groups,
while group B meningococcus infections were prevalent among young adults. The need for a new vaccination for preventing group B meningococcus infections
in Finland will be assessed in the near future.
The annual number of new cases of tuberculosis
dropped clearly below 300 for the first time ever in the
year under surveillance. Antimicrobial susceptibility of
causative strains remained good, although last year also
marked the discovery of Finland’s first strain of tuberculosis bacteria resistant to nearly all drugs (XDR).
The number of measles cases was clearly less than
in the previous year; these involved unvaccinated
patients having contracted the infection on a trip
abroad in all cases except one.
The incidence of tularemia tripled from the previous year. Regarding tick-borne encephalitis (TBE),
further confirmation of new risk areas outside Åland
was obtained by investigating the location of patients
during the probable time of contracting the infection.
These data will be used to assess the need to deploy
TBE vaccination to persons other than those resident
in and travelling to Åland. The number of cases of
Pogosta disease increased on the previous year.
The number of cases of dengue fever in tourists has
been steadily increasing in recent years; infections
originating in Madeira are a new phenomen.
The number of infections confirmed by blood culture
continued to grow in the age group of over 65, while
decreasing in the age group of under 15. An epidemic
of severe cases of Group A streptococcus occurred in
the Satakunta Hospital District.
Helsinki, 10 April 2013
Petri Ruutu
Head of Department
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Infectious Diseases in Finland 2012
Respiratory infections
• Influenza A became the dominant virus in the 2011–2012 season, and the A(H3N2)
subtypes differed from the virus included in the seasonal vaccine.
• The B influenza epidemic of the 2012–2013 season began early, in November and
December.
• The RSV winter epidemic of 2011 was more extensive than in the previous year,
lasting from December 2011 to April 2012.
• The second peak of the dual-peak Mycoplasma pneumoniae epidemic occurred in
winter 2011–2012.
Influenza
After a pause of two years, viruses of the influenza
A(H3N2) subtype emerged as the dominant epidemic virus in the 2011–2012 season. The season began gradually in January 2012, peaking in February
and continuing to decline throughout March. However, the number of influenza B infections concurrent
with influenza A was notably lower than in the previous season, 2010–2011.
Influenza A
In 2012, 5,960 cases of influenza A were reported
to the NIDR, more than three times higher than in
the previous year (2011: 1,900). In the national surveillance of influenza virus infections at the virology
unit of the National Institute for Health and Welfare,
220 influenza A infections were detected, more than
90% of them caused by the influenza A(H3N2) virus. Only isolated cases of influenza A(H1N1)pdm09
infections were reported during winter 2012.
children aged 6 to 35 months, the highest number
of influenza A cases was reported in the age group
of 0 to 4 (n=851). The elevated morbidity in this
age group may be due to poor vaccination coverage,
which may have been influenced by the association
of the 2009 pandemic vaccination (Pandemrix) with
cases of narcolepsy and the low number of influenza
virus infections of the subtype A(H3N2) during the
two previous epidemic seasons.
The genetic diversity of both A(H3N2) and A(H1N1)
pdm09 influenza virus subtypes increased during
2011. Several genetic groups were found in both influenza A subtypes in early 2012.
The first isolated influenza A infections were reported
in late 2011, but their occurrence did not begin to
increase until January 2012. Data in the NIDR and
the national influenza surveillance of the National Institute for Health and Welfare indicate that the epidemic in the 2011–2012 season peaked in weeks 5
to 9. During March, the number of cases began to
decline, and at the end of April only isolated cases
were reported.
The epidemic viruses of the influenza A(H3N2)
group circulating worldwide comprised two distinct genetic groups, Perth/16/2009 and Victoria/208/2011, with some antigenic differences. Further genetic subgroups may be detected within these
two groups. In the seasonal influenza vaccination for
the 2011–2012 season, the A(H3N2) component
was the Perth/16/2009 strain, the incidence of which
worldwide in winter 2012 was lower than that of the
Victoria/208/2011 strain. In the national influenza
surveillance of the National Institute for Health and
Welfare, all the genetically typed influenza viruses of
the A(H3N2) subtype were of the Victoria/208/2011
strain, which was not included in the vaccine. The viruses of the Victoria/208/2011 strain that circulated
in Finland represented two different genetic subtypes
also frequently found elsewhere in Europe.
Influenza A infections were found in all age groups.
Although the national influenza vaccination programme offers a seasonal influenza vaccination free
of charge for children in at-risk groups and healthy
Although a significant percentage of the influenza A
infections diagnosed proved to have been caused by
influenza A(H3N2) virus strains, isolated cases of influenza A(H1N1)pdm09 subtype were also reported
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Infectious Diseases in Finland 2012
H1N1pdm09
7500
4000
H3N2
3500
3000
2500
H3N2
2000
H3N2
1500
H3N2
1000
H1N1
H3N2
500
H3N2
H1N1pdm09
H1N1
H1N1pdm09
H3N2
H3N2
H1N1
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 1. Cases of influenza A by month, and epidemic virus serotypes 2001–2012 (no. of cases).
in Finland. The cases of influenza A(H1N1)pdm09
represented two genetic groups also frequently found
elsewhere in Europe; no antigenic differences were
detected between these groups or between them and
the A/California/07/2009 vaccine virus.
2011–2012 season contained an influenza B virus of
the Victoria lineage. The virus strains from the Victoria lineage found in Finland were both genetically
and antigenically similar to the vaccine virus, B/Brisbane/60/2008.
Influenza B
Vaccine for the epidemic season 2012–2013
Following the major influenza B epidemic of 2011,
only 462 cases of influenza B were reported to the
NIDR in 2012 (2011: 3,444). The incidence of influenza B infections during winter and spring 2012
(January to May) was low but steady. Isolated cases
were also reported in the summer and autumn. The
number of cases of influenza B began to increase
again towards the end of the year, in November and
December, nearly equally in all age groups. The incidence of influenza B infections was slightly lower in
the age group of over 60 than in other age groups.
Based on reports of the epidemic influenza A and B
viruses circling the world, the WHO recommended a change to the vaccination composition in the
Northern Hemisphere for the epidemic season 2012–
2013. The recommendation was that the influenza
A(H3N2) virus component be changed to A/Victoria/361/2011, while retaining the A(H1N1)pdm09
component as A/California/07/2009.
Of the two influenza B lineages circling the world,
viruses of the Victoria lineage have been principally generating epidemics. Virus strains from both
the Victoria and the Yamagata lineages were found
in Finland in 2010−2011, the slight majority being
from the former. The influenza B viruses typed at the
virology unit of the National Institute for Health and
Welfare in winter 2012 were all of the Victoria lineage, although worldwide the Yamagata lineage is becoming more prevalent. The influenza vaccine for the
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Because of international recommendations, only one
lineage of influenza B may be included in the seasonal influenza vaccination used in Finland for the
time being. The increased incidence of viruses of the
Yamagata lineage worldwide led the WHO to recommend replacing the influenza B Victoria lineage component in the vaccine (B/Brisbane/60/2008) with a
Yamagata lineage component, B/Wisconsin/1/2010.
Season 2012–2013
The first cases of influenza A and B infections were
reported in November and December 2012. The
first reported influenza A infections involved both
Infectious Diseases in Finland 2012
1800
Victoria,
Yamagata
1600
1400
1200
1000
800
Yamagata
600
Victoria,
Yamagata
400
200
Victoria
Victoria,
Yamagata
Yamagata
Yamagata
Victoria,
Yamagata
Yamagata
Yamagata
Victoria
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 2. Cases of influenza B by month, and epidemic virus serotypes 2001–2012 (no. of cases).
A(H3N2) and A(H1N1)pdm09 strains, while the
influenza B infections involved viruses of the Victoria lineage. The epidemic season proper started at
the end of January 2013, peaking after mid-February.
Throughout the season, cases of A(H3N2), A(H1N1)
pdm09 and B viruses were reported, though as the
season progressed, the relative incidence of cases of
A(H1N1)pdm09 increased.
the egg-based A/Victoria/361/2011 component currently used in the vaccine.
Detailed analysis of the epidemic viruses circulating
Finland in the 2012–2013 season has not yet been
completed, but preliminary findings show that the influenza viruses found were very similar to the influenza A(H3N2) and influenza A(H1N1)pdm09 components in the seasonal vaccine. The majority of the cases
of influenza B viruses in Finland were of the Victoria
lineage, differing from the B virus component in the
vaccine. Both viruses of the Yamagata lineage circling
the world, differing from one another genetically and
antigenically, were also found in Finland.
RSV
At the end of February 2013, the WHO issued a
new vaccine recommendation for the northern hemisphere 2013–2014 epidemic season, based on the
then current epidemic situation. The WHO now recommended that the influenza A(H1N1)pdm09 component should be A/Christchurch/16/2010, which
antigenically corresponds to the earlier A/California/07/2009 vaccine component. Similarly, the WHO
recommended that the H3N2 component, A/Victoria/361/2011, be replaced with A/Texas/50/2012,
which is a better antigenic match to the current epidemic viruses resembling A/Victoria/361/2011 than
The influenza B component was changed to B/Massachusetts/2/2012, which is also a virus of the Yamagata
lineage but differs antigenically from the component
previously used in the vaccine.
In 2012, 2,346 cases of RSV confirmed with laboratory tests were reported to the NIDR (2011: 1,524).
In long-term surveillance , a major RSV epidemic has
been observed in Finland every other winter, often
starting in November or December, with a minor epidemic occurring between the major ones. The low
number of cases reported in 2011 was due to the occurrence of a minor epidemic in the spring (March–
April), followed by the biennial major winter epidemic that did not begin until December 2011 but
continued until April 2012.
The incidence of RSV varied by hospital district (7–
94/100,000), most likely caused by differences in the
use of laboratory diagnostics. As in earlier years, the
majority of RSV cases (more than 80%) were found
in children aged 0 to 4. Although infections presented in all age groups, cases requiring hospitalisation
and laboratory diagnostics mostly involved infants
and small children.
Reliable quick tests for RSV diagnostics have been
developed for use at health care centres, outpatient
Report 12/2013
National Institute for Health and Welfare
9
Infectious Diseases in Finland 2012
1400
1200
1000
800
600
400
200
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Figure 3. Cases of RSV per month, 2001–2012 (no. of cases).
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.
Legionella
In 2012, 62 suspected findings of legionellosis were
reported to the NIDR. The diagnosis was based on
detection of antigen in the urine in 4 cases, on detection of nucleic acid in sputum, and on serological methods in the rest. Further study showed that
the clinical presentation was consistent with legionella pneumonia in only 11 cases (17%). Of these,
four tested positive for legionella antigen in urine,
one tested positive for nucleic acid in sputum, and
in six cases the diagnosis was made using serological methods. The majority of the patients diagnosed
with legionella pneumonia (10 out of 11) were men
aged between 44 and 80; the one other patient was a
16-year-old woman. All except one patient had been
abroad before falling ill. The patient who had fallen
ill in Finland had a severely compromised immune
system due to underlying illness.
The accommodation data of six of the patients who
fell ill abroad were reported to ELDSNET (European
Legionnaires’ Diseases Surveillance Network), which
collects data on travel-related legionellosis.
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National Institute for Health and Welfare
Finland has no national guidelines concerning the
locating of an environmental source in cases of legionellosis or related epidemic prevention. The most
recent European guidelines for travel-related cases of legionellosis are the EWGLI guidelines from
2011 (http://www.escmid.org/fileadmin/src/media/
PDFs/3Research_Projects/ESGLI/European_Guidelines_September_2011_v1_1.pdf ) and the ELDSNet guidelines from 2012 (http://ecdc.europa.eu/
en/publications/Publications/1202-TED-ELDSNetoperating-procedures.pdf ).
Whooping cough
The number of cases of whooping cough reported in
2012 was 536 (9.9/100,000), almost exactly the same
as in the previous year (2011: 555; 10/100,000). The
cases were concentrated in the age groups of 10 to 19
and under 12 months: 43 of the patients were under
12 months old, with 24 under three months old. The
diagnosis of nearly all (40) patients under 12 months
old was based on a PCR test, while the majority of rest
of the cases were diagnosed from antibody testing.
All the strains found, except for one strain of B. pertussis (1/21), produced pertactin, one of the components of the vaccine used in Finland.
As in earlier years, the incidence of whooping
cough varied considerably by hospital district (0–
18.6/100,000), being highest in North Karelia, while
the Länsi-Pohja Hospital District reported no cases
at all. At the Central Finland Central Hospital, the
Infectious Diseases in Finland 2012
500
450
400
350
300
250
200
150
100
50
0
2001
2002
2003
0−4
2004
5−9
2005
2006
10−14
2007
15−19
2008
2009
20−24
2010
2011
2012
25−29
Figure 4. Cases of whooping cough in children’s and young adults’ age groups 2001–2012 (no. of cases).
entire personnel of the paediatrics ward were given a
course of antibiotics in October 2012 when one employee was diagnosed with whooping cough.
Choosing an optimum vaccination strategy for
whooping cough is difficult, as the available vaccines
are incomplete in efficiency and duration. A booster
for six-year-olds was added to the national vaccination
programme in Finland in 2003. In 2005, the wholecell vaccine was replaced with a cell-free vaccine for
children in the age groups covered by child care clinics. Until 2007, adolescent vaccinations were given between the ages of 11 and 13. Since 2009, the recommendation has been to vaccinate adolescents at the age
of 14 to 15, i.e. beginning in the 8th grade of comprehensive school. Because of the transition, very few
vaccinations were given between 2009 and 2011. This
created a temporarily less well protected cohort in adolescent age groups. Illness in infancy indicates insufficient herd immunity. Nevertheless, Finland has so far
been spared the extensive whooping cough epidemic
that generated more than 40,000 cases in the USA and
almost 10,000 cases in the UK during 2012.
Adenovirus
In 2012, almost 700 confirmed cases of adenovirus
infection were recorded (2011: 800). The largest
number of cases was in the age group of under 5, but
there were also numerous cases in the age groups 15
to 19 and 20 to 24. The number of cases was highest in February and March (more than 100 cases per
month) and lowest in June (21 per month).
There are 57 known types of adenovirus. Some of
them cause respiratory infections, while others cause
intestinal, eye or other infections. Adenoviruses are
common pathogens in infants and small children;
they occur more rarely in adults. Adenovirus infections among conscripts tend to appear as epidemics
whenever new arrivals enter service, particularly in
February and March, i.e. after the annual influenza
epidemic. The adenovirus epidemic in winter 2012
partly coincided with the influenza epidemic, peaking in February and March. In summer 2012, adenovirus activity was relatively low, but the incidence
increased again in the autumn.
Laboratories use various testing methods to detect
adenoviruses in clinical samples. Antigen detection,
virus cultures and PCR are sensitive and reliable
methods used at specialised virus laboratories.
Parainfluenza
Parainfluenza viruses are gathered under the same
heading in the NIDR, even though laboratories
often separate parainfluenza viruses 1, 2 and 3. In
2012, 401 parainfluenza infections were confirmed
(2011: 279), most of them in the age group 0 to 4.
The highest monthly number of cases (80 to 100) was
recorded in April and May. 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
Report 12/2013
National Institute for Health and Welfare
11
Infectious Diseases in Finland 2012
1600
1400
1200
1000
800
600
400
200
0
2001
2002
2003
2004
2005
2006
2007
Mycoplasma pneumoniae
2008
2009
2010
2011
2012
Chlamydia pneumoniae
Figure 5. Cases of Mycoplasma pneumoniae and Chlamydia pneumoniae per month, 2001–2012 (no. of cases).
respiratory tract infection and requires no laboratory
diagnostics. In special groups, however, such as immune deficiency patients, parainfluenza viruses can
cause quite serious symptoms. Parainfluenza virus
type 3 causes minor epidemics in the summer and
autumn nearly every year. Type 1 and 2 viruses, on
the other hand, do not cause epidemics every year.
Parainfluenza viruses, especially type 1, typically
cause laryngitis in small children.
Mycoplasma pneumoniae
In winter 2011–2012, Finland saw the second peak
of a Mycoplasma pneumoniae epidemic, which is generally dual-peaked. In 2012, more than 4,600 further
laboratory-confirmed cases of M. pneumoniae were reported; the number of cases in the previous year had
been more than 7,800. Increased awareness among
both health care personnel and the general public increased sampling activity and hence the number of
diagnoses. As in the previous year, the majority of
cases (more than 1,600) were recorded in the Helsinki and Uusimaa Hospital District. The incidence,
however, was highest in the Vaasa and Pohjois-Savo
Hospital Districts in 2012 (>140/100,000).
As the number of cases increased, cases with rare
symptoms associated with M. pneumoniae infection
emerged: there were reports during the epidemic in
Finland of cases presenting with symptoms and findings beyond the respiratory system (such as StevensJohnson syndrome limited to mucous membranes).
Atypical symptoms pose additional challenges to
12
Report 12/2013
National Institute for Health and Welfare
laboratory-based diagnostics. It now seems likely that
we are in a lull of several years between epidemics.
We should now review and improve our diagnostic
potential and engage in research on macrolide resistance in M. pneumoniae, as this has been increasing
worldwide.
Chlamydia pneumoniae
In 2012, 205 cases of Chlamydia pneumoniae were
reported based on antibody testing. This was half the
amount that was reported in 2011. The highest incidence was recorded in the Central Ostrobothnia
Hospital District, where it remained high and stable
compared with the previous year (19 vs. 23/100,000).
In the Länsi-Pohja, South Karelia, North Karelia, Lapland and Southwest Finland Hospital Districts, the
incidence was also higher (7–9/100,000) than the
national average (4/100,000). As in previous years,
most of the infections were found in patients aged
10 to 14.
Infectious Diseases in Finland 2012
Gastrointestinal infections
• An EHEC outbreak at an agritourism site was transmitted through unpasteurised
milk and animal contact.
• More cases of listeria were reported than in the previous year. Meat jelly was
suspected as the source of the outbreak.
• Five suspicions of a cryptosporidiosis outbreak were reported towards the end of
the year; Dutch salad was the suspected source of infection.
• The increasing number of cases of norovirus infection was due to new virus
variants.
• There were notable regional differences in the incidence of Clostridium difficile.
Salmonella
The number of salmonella cases reported in 2012
was 2,199 (2011: 2,099); 55% of the patients were
women. Annual incidence in the entire country was
41/100,000 population. The incidence was highest in the Helsinki and Uusimaa Hospital District
(53/100,000) and lowest on Åland (18/100,000).
The highest number of infections was reported in the
age group 20 to 29.
There was one case of S. Typhi causing typhus (contracted in India) and four cases of S. Paratyphi causing paratyphoid fever. The latter included one case
of S. Paratyphi B (contracted in Malaysia) and three
cases of S. Paratyphi A (two contracted in India and
one in Finland).
The bacterial strains from a total of 1,978 cases of
salmonella were typed at the National Institute for
Health and Welfare: 1,557 (79%) were of foreign origin and 407 (21%) of domestic origin. The number
of domestic cases was somewhat higher than in previous years, and the incidence was 7.5/100,000. In 14
cases, the origin of the salmonella infection remained
unclear.
Domestic salmonella infections were caused by 52
different serotypes. The four most common were
Typhimurium (98/407, 24%), Enteritidis (83), Infantis (36) and Group b (35). Over the past two
years, a new sub-group has emerged within Group
B: monophasic S. Typhimurium. In 2012, they accounted for 25 domestic cases (2011: 35; 2010: 5;
2009: 5). Most of these monophasic Typhimurium
strains were multiresistant (ampicillin, streptomycin,
sulfonamide and tetracyclin) and of phage type FT
193. In 2011, most of them were of phage type FT
195. Neither phage type is known to occur in domestic farm animals. In other domestic cases of Typhimurium, the percentage of the indigenous FT 1
phage type continued to decline year on year (2012:
23%; 2011: 60%). The second most common phage
type was FT U277 (17%). Unspecified phage types
that caused a reaction (FT NST) were found in 17%
of the cases. The FT 1 strains were divided into six
genotypes, most of which (77%), as in previous years,
were of the genotype STYM 1, which is susceptible to antimicrobials. Most (88%) of the domestic
Typhimurium strains were further typed using the
MLVA method based on differences between repeated sequences in DNA; the most common MLVA profile was 3-16-NA-NA-0311 (21%), as in the previous
year. Most of these were FT 1, STYM 1 strains.
There were more cases caused by the domestic Enteritidis serotype in the year under surveillance than
in the previous year (83 vs. 47). These were divided
into ten phage types, the most common being phage
types FT 1B (50%) and FT 8 (13%). NT and NST
strains accounted for 8%. Of the domestic Enteritidis
strains, 71% were genotyped. There were 16 genotypes found in all, the most common being SENT
117 (41%), which was associated with phage types
FT 1B and FT 1.
The salmonella infections acquired abroad represented
119 serotypes. The most common serotypes were the
same as in the previous year: Enteritidis (480/1,557,
31%), Group B (143), Stanley (98) and TyphimuReport 12/2013
National Institute for Health and Welfare
13
Infectious Diseases in Finland 2012
Table 1. The most common serotypes of salmonella cases, 2001–2012 (excluding S. Typhi and S. Paratyphi) (no.
of cases).
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Infection acquired abroad (Source: NIDR)
Salmonella Enteritidis
1243
904
887
758
834
879
735
1066
657
778
612
544
32
33
23
37
38
55
93
166
119
103
144
161
Salmonella group B
Salmonella Stanley
63
65
67
105
113
116
175
136
111
98
68
99
Salmonella Typhimurium
143
115
155
183
194
141
246
198
166
142
80
83
Salmonella Infantis
34
20
16
33
39
31
54
31
42
42
31
44
Salmonella Corvallis
21
10
40
39
60
56
59
70
68
42
45
42
Salmonella Braenderup
45
50
26
16
16
32
53
37
39
38
22
37
Salmonella Agona
24
29
21
26
23
25
20
33
22
25
23
32
Salmonella Newport
57
47
40
53
47
66
57
76
54
54
32
31
Salmonella Virchow
79
55
67
74
88
80
135
115
90
77
35
31
Other
635
516
520
516
493
546
646
678
571
631
525
572
Total
2376
1844
1862
1840
1945
2027
2273
2606
1939
2030
1614
1676
Domestically acquired infections (Source: Bacteriology Unit)
Salmonella Typhimurium
152
222
137
132
241
170
150
80
134
132
94
98
Salmonella Enteritidis
63
42
61
81
75
69
61
49
48
44
47
83
Salmonella Infantis
19
4
4
4
11
6
3
7
2
9
10
36
Salmonella group B
2
3
2
7
1
4
11
5
7
8
40
35
Salmonella Agona
41
16
12
27
32
11
40
15
2
2
11
33
Salmonella Abony
3
15
7
7
2
0
0
2
2
8
4
16
Salmonella Isangi
0
1
0
1
0
0
0
1
0
1
0
11
Salmonella group E
0
0
0
0
1
1
0
0
1
7
13
11
Salmonella Newport
5
3
16
8
3
9
23
70
9
8
6
7
Salmonella London
1
0
1
2
0
2
0
2
0
2
2
6
Salmonella Napoli
1
0
3
2
0
2
0
2
0
6
6
3
Salmonella Oranienburg
0
7
4
1
1
0
0
7
2
2
43
2
Other
103
93
63
64
76
123
84
134
102
105
62
66
Total
390
406
310
336
443
397
372
374
309
334
338
407
1000
900
800
700
600
500
400
300
200
100
0
2001
2002
2003
2004
2005
2006
Salmonella
2007
2008
2009
Campylobacter
Figure 6. Salmonella and campylobacter cases by month, 2001–2012 (no. of cases).
14
Report 12/2013
National Institute for Health and Welfare
2010
2011
2012
Infectious Diseases in Finland 2012
rium (92). The majority (55%) of the foreign cases
caused by Group B were caused by the monophasic,
multiresistant phage type FT 193 of S. Typhimurium
(the most common resistance profile being ASSuTe
and the most common source being Thailand). In the
remaining foreign cases too, the most common source
was Thailand (34%), followed by Turkey (9%), Spain
(5%) and Egypt (4%).
There were 470 strains phage-typed from the foreign
Enteritidis strains and 92 from the Typhimurium
strains. The most common phage types of Enteritidis
were FT 8 (15%; from 18 countries, largest number
from Turkey), FT 14 B (13%; from six countries,
largest number from Turkey and Spain) and FT 1B
(10%; from 17 countries, largest number from Estonia). The most common phage types of Typhimurium were FT 195 (19%; from five countries, largest number from Thailand), FT NST (19%; from 15
countries) and FT 120 (11%; from five countries).
Campylobacter
In 2012, the NIDR received 4,251 notifications
of campylobacter infections, the same as in 2011.
Campylobacter jejuni remained the single most common type of campylobacter (2,349 cases); there were
163 reported cases of C. coli, and no fewer than 1,737
cases where the campylobacter type was not specified.
The hippurate test used to distinguish between types
has been abandoned in some laboratories, because it
cannot correctly identify all strains. A positive hippurate test does identify C. jejuni rather reliably, but
a negative result is not reliable for identifying C. coli:
nearly 30% of such strains may be hippurate-negative
C. jejuni.
The incidence rate in the entire population was
78/100,000. Of the patients, 54% were men. The
highest number of cases was reported in the age
group 20 to 54 (>100/100,000). Incidence was highest in the hospital district of Helsinki and Uusimaa
(113/100,000).
The seasonal variation was typical for campylobacter:
incidence was highest in July and August (Figure 6).
Of the cases in 2012, 726 (17%) were domestic in
origin, although 41% of the cases lacked data on the
country of acquisition. Foreign travel was a factor in
1,797 of the cases (42%); the most common source
was Thailand (361), followed by Spain (230) and
Turkey (219).
Yersinia
Under the Communicable Diseases Decree, cases of
yersinia must be reported to the NIDR but not sent
to the strain collection of the National Institute for
Health and Welfare. However, species typing and biotyping/serotyping yersinia strains may pose a problem
for clinical microbiology laboratories. Yersinia strains
may be sent to the National Institute for Health and
Welfare for typing if necessary.
Yersinia enterocolitica
In 2012, the NIDR received 497 reports of Yersinia
enterocolitica, 3% fewer than in 2011 (514). The nationwide incidence was 9.2/100,000. Based on the
cases reported to the register, the incidence was lowest among those under 20. There is great regional
variation in the Yersinia enterocolitica findings, being
highest in the Hospital District of Helsinki and Uusimaa (17/100,000), while no cases at all were recorded
on Åland.
Y. enterocolitica is most commonly confirmed from
a stool culture. In 2012, stool culture was used for
confirming 410 cases, while only 82 cases were typed
by antibody findings in serum; in five cases, both antibody typing and a stool culture were used. Y. enterocolitica findings were reported in just over half of
the cases confirmed by culture, and thus conclusions
about the percentages of the various biotypes or serotypes are uncertain. Nevertheless, the majority (69%)
of the strains typed were of biotype 1A (45% of all
cultured cases of Y. enterocolitica). Y. enterocolitica
strains of biotype 1A are a highly heterogeneous
group of strains lacking the pYV virulence plasmid
typical of pathogenic yersinias. Therefore, the biotype
1A strains are considered non-pathogenic. However,
some strains may have other properties affecting their
pathogenic capabilities. A separate study found that
Y. enterocolitica bacteria isolated from elderly patients
tend to be biotype 1A strains, while the pathogenic
strains of bio/serotypes BT2/O:9 and BT3-4/O:3 are
over-represented in small children.
Yersinia pseudotuberculosis
The number of cases of Yersinia pseudotuberculosis
doubled on the previous year (56 vs. 28). The majority of the cases (45) were confirmed by culture and
only 10 by antibody findings; both were used in one
case. In 2012, the incidence in the entire country was
1.0/100,000 population. The figures are too low to
indicate regional variation. In 2012, no infections
were detected in eight hospital districts. Epidemics
cause variation in the annual incidence of cases of Y.
pseudotuberculosis. However, a cluster of three infecReport 12/2013
National Institute for Health and Welfare
15
Infectious Diseases in Finland 2012
tions in children was noted in the Tampere Region
in 2012.
Shigella
In 2012, the incidence of shigellosis was 1.6/100,000.
There were 93 reported cases, 32 in men and 61 in
women. The median age of the cases was 37 years
(range 1 to 72); the majority of cases (61) was in the
age group 20 to 49. More than half of the cases (55)
were reported in the Helsinki and Uusimaa Hospital District. Six hospital districts had no diagnosed
cases. Of the total, 88 infections (95%) were reported as having been acquired abroad and three in
Finland. In two cases, the country of acquisition was
not specified. One person had an infection caused by
two different strains of shigella, contracted in India.
The most common countries of origin were India (24
cases), Egypt (7) and Cape Verde (7). The prevailing shigella species were Shigella sonnei (61 cases) and
S. flexneri (23 cases). Only three cases of S. dysenteriae were reported (no shigatoxin-producing serotypes
were among the pathogens). Four strains (countries
of acquisition: Ethiopia, Cape Verde, Mozambique,
Myanmar) could not be typed and will be sent to
the EU reference laboratory for further study. All the
above strains had the ipaH gene, which is typical only
of Shigella and enteroinvasive E. coli (EIEC). Both
bacteria cause similar infections, and they have a low
infectious dose, which is why they can both easily
lead to a secondary infection. However, because only
shigellosis is classified as a generally hazardous communicable disease in the Communicable Diseases
Decree and because earlier experience has shown that
ipaH-positive strains have proven to be shigella, these
strains were also labelled Shigella sp.
Strains of serotype O157:H7 caused a total of 22 cases. They were divided into four phage types, the most
common being FT 88 and FT 8. Eight of these cases
were linked to the Turku agritourism outbreak, and
the strains were of phage type FT 88, positive with regard to the shigatoxin-producing stx2 gene, sorbitolpositive, immobile despite H antigen, and identical
in genotype. There were 7 cases of serogroup NonO157. The strains isolated from these were typed into
the O groups O26, O103, O111, O117 and O145.
For one strain, the O antigen remained untyped
(ONT).
Of the 2012 strains, 80% were multiresistant (resistant to at least 4 out of 12 antimicrobials tested), and
45% were completely resistant or had reduced susceptibility to ciprofloxacin (MIC 0,125–12 mg/l).
Two of the strains were resistant to cefotaxime.
The norovirus epidemics in 2012 were caused in
many cases by norovirus variant GII.4 2010, which
is a recombination of two earlier GII.4 variants that
emerged in 2006 and 2008. In a handful of cases, the
pathogen was found to be an earlier, now rare variant
of norovirus, GII.4 2006b. An outbreak in Ylöjärvi
in autumn 2012 was found to have been caused by
a new variant of GII.4 that had emerged in 2012.
Although this Sydney 2012 variant shares the same
ancestor as two earlier GII.4 variants that emerged in
2007 and 2009 (Appeldoorn and New Orleans), its
genome is different. This is probably what explains its
high epidemic activity. During the autumn, reports
of exceptionally widespread hospital epidemics were
received from around the world. There were also individual epidemics caused by other genotypes (GI.4,
GI.b, GI.7, GII.b, GII.7, GII.g) in 2012.
Enterohaemorrhagic
Escherichia coli (EHEC)
In 2012, 30 microbiologically confirmed cases of
enterohaemorrhagic Escherichia coli (EHEC) were
reported to the NIDR (0.6/100,000). Of these patients, 16 were women and 14 were men. The patients were under the age of 15 in 15 cases, nine of
them under the age of 5. Six children were diagnosed
with haemolytic-uremic syndrome (HUS) as a complication. Eight of the cases were related to an out-
16
break at an agritourism site in Turku. Seven further
patients had had contact with a farm, according to
interviews, and an EHEC strain identical with the
patient strains was found on three farms. There were
six cases where the infection was acquired abroad.
Report 12/2013
National Institute for Health and Welfare
Norovirus
In 2012, 1,748 cases of norovirus were reported,
clearly more than in 2011. There were 965 women
among the patients (55%), and 74% of the cases were
reported between January and May. Although more
than half of the cases (52%) involved patients over
the age of 75, norovirus cases were reported in all age
groups. Cases were reported in all hospital districts.
The year 2012 was the fifth 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 (2007–2011), most of the epidemics that occurred in 2012 were institutional epidemics. This also explains the high incidence among
the elderly.
Infectious Diseases in Finland 2012
900
800
700
600
500
400
300
200
100
0
2005
2006
2007
2008
2009
2010
2011
2012
Figure 7. Cases of norovirus infection per month, 2005–2012 (no. of cases).
Norovirus has become one of the most common causes of food- or water-borne epidemics in the 2000s. In
2012, food-borne epidemics were caused by noroviruses of both genogroup I and genogroup II.
Rotavirus
Only 209 rotavirus cases were reported in 2012, less
than a tenth of the number reported in 2006. The rotavirus vaccine was launched on the Finnish market
in summer 2006. Initially, the vaccine was not widely
used, but in 2008 as many as one in three children
were vaccinated against the rotavirus (the cost of the
vaccine was paid by parents). The rotavirus vaccine
was finally added to the national vaccination programme in September 2009.
The highest incidence by far was again in the age
group of under 5 (41/100,000), but this was less than
a tenth of the average incidence before the vaccination
programme (460/100,000 in this age group), and the
downward trend continues. With increasing vaccination of infants, the percentage of cases in older age
groups will increase. In 2012, 44% of all cases were in
patients aged 5 or over, whereas this figure was never
higher than about 10% in previous years. However,
the incidence is decreasing in all age groups.
In 2012, most of the cases were caused by rotavirus serotypes G1P[8], G4P[8], G3P[8], G2P[4] and
G9P[8], as in earlier years. 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 2012, 165 enterovirus cases were reported to the
NIDR, slightly fewer than in 2011 (219). Men accounted for 72 (44%) of the cases. Less than half (62,
38%) of the patients were under the age of 10, and
the majority of cases involved patients under the age
of 20. The outbreak peaked in September and October. Several different enteroviruses were identified
as the pathogens: CV-A6, CV-A16, CV-B2, CV-B3,
echovirus 6, 9, 11, 18, 19 and enterovirus 96. No
significant epidemic clusters were found.
Enteroviruses cause conditions such as aseptic meningitis, encephalitis, myocarditis and typical enteroviral
conditions (hand, foot and mouth disease, epidemic
myalgia, etc.). 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, especially
if the patient presents with neurological symptoms.
Stool cultures also enable the monitoring of the possible circulation of polioviruses in the population;
this monitoring is important and necessary even in
Finland.
Report 12/2013
National Institute for Health and Welfare
17
Infectious Diseases in Finland 2012
1400
1200
1000
800
600
400
200
0
2005
2006
2007
2008
0–3 months
2009
4–11 months
2010
2011
2012
1–4 years
Figure 8. Rotavirus cases by age group in children aged 0 to 4, 2005–2012 (no. of cases).
Listeria
Clostridium difficile
There were 62 infections caused by Listeria monocytogenes reported in 2012 (2000–2010: 18–71; 2011:
44). About half of the patients were over the age of
70; men and women were equally represented. Although pregnancy is not one of the factors reported
to the NIDR, it is known that the cases include one
mother-and-child pair. The listeria cases were spread
out across the country. An outbreak of 12 cases was
caused by PFGE type 225. In addition to the cases
reported to the NIDR, this genotype was found in
the stool samples of patients with gastroenteritis accompanied by fever during the outbreak. Diarrhoea
caused by listeria is not a notifiable communicable
disease.
Clostridium difficile has been a finding reportable to
the NIDR from the beginning of 2008. More than
6,000 cases were reported in 2012 (2011: >6,000;
2010: >6,000; 2009: >7,000; 2008: >8,000), out of
which 5,256 (2011: 5,382; 2010: 4,804; 2009: 5,700;
2008: 6,301) involved a toxin-producing strain. Almost 60% of patients diagnosed with C. difficile were
women, and about half were 75 years of age or older.
The number of toxin-positive strains in patients under the age of 15 was 182 (3%) (2008–2011: 2–3%),
of which one in four were isolated in patients under
the age of 12 months. There were notable regional
differences in incidence (32–249/100,000), being
highest in the Central Ostrobothnia, Kymenlaakso,
Lapland and North Ostrobothnia Hospital Districts.
Listeria cultures from the blood and/or CSF of 60
patients were sent for typing. A further eight strains
isolated from stool samples related to the listeria outbreak were typed. The PCR method was now used
for determining the Listeria monocytogenes serotype.
It was found that 49 (72%) of the strains typed were
of serotype IIa (corresponding to serotype 1/2a with
the earlier method) and 15 (22%) of serotype IVb
(4b); there were two cases each (3% each) of serotypes IIb (1/2b) and IIc (1/2c). These strains were divided into 32 PFGE genotypes. The most common
listeria strain, which caused the outbreak (serotype
IIa, PFGE type 225), was found in 20 patients.
18
Report 12/2013
National Institute for Health and Welfare
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. In the year under surveillance, 235 strains
(4.5% of the number of cases reported) were typed at
the National Institute for Health and Welfare. Nine
hospital districts sent strains for typing. There were
50 ribotypes found in all, 30 of which were internationally named ribotypes and 11 were new ribotypes
not previously found in Finland. The percentage of
severe cases among the typed strains increased on
the previous year, being caused by a number of ribotypes, most commonly ribotype 001. Nucleic acid
based methods have become significantly more common in diagnostics. For a considerable percentage of
Infectious Diseases in Finland 2012
2500
2000
1500
1000
500
0
Central Finland
Southern
-
Vaasa
Bothnia
Central
Bothnia
Northern
Bothnia
Kainuu
Western
Bothnia
Lapland
Åland
Helsinki and
Uusimaa
2500
2000
1500
1000
500
0
Southwest
Finland
Satakunta
Kanta-Häme
Pirkanmaa
Päijät-Häme
Kymenlaakso
Southern
Karelia
Southern
Savo
Eastern
Savo
Northern
Karelia
Northern
Savo
Figures 9a and 9b. Cases of Clostridium difficile by hospital district, 2001–2012 (no. of cases).
the typed strains, potential hypervirulence was given
as a background detail; in other words, the submitting laboratories had performed toxin gene profiling
for these strains. Out of these potentially hypervirulent ribotypes, 023 and 078 are now among the most
common, while the occurrence of 027 has notably
decreased, to 4.3%. Other common ribotypes, as in
previous years, were 001, 002, 014, 020, 005 and
011. Ribotype 176 was a new finding; this resembles
027 in its toxin gene profile (toxins A & B, binary toxin, 18bp deletion in TcdC, point mutation at
117bp) but differs clearly in its MLVA profile and in
ribotyping by a single strand.
Food-borne epidemics
Since the beginning of 2010, municipal epidemic
investigation working groups have 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 2012, 88 such notifications were entered. Several other gastrointestinal
infection clusters were investigated as well.
Nearly 100 people fell ill in Salmonella
Agona outbreak
In June, Salmonella Agona caused an outbreak at a
summer party in Helsinki: nearly 100 people fell ill.
Salmonella was not found in the food samples stud-
Report 12/2013
National Institute for Health and Welfare
19
Infectious Diseases in Finland 2012
ied, nor could a correlation be established in a survey between any specific dish and the infection. The
source of the infection was most likely an uncooked
ingredient in one of the foods served.
EHEC outbreak transmitted through
unpasteurised milk and animal contact in
Turku
In June, six children contracted an EHEC bacterial
infection (O157:H7, phage type FT 88, sorbitol-positive strain) in the Turku region. Five of them were
hospitalised in intensive care because of haemolyticuraemic syndrome (HUS). Prior to falling ill, the patients had visited a local agritourism farm or drunk
unpasteurised milk from that farm. A strain of EHEC
identical to that found in the patients was found in
the cattle on the farm and in environmental samples
from the farm. The number of people exposed to and
infected by EHEC and the transmission routes of the
EHEC bacteria were explored through a survey conducted jointly with the City of Turku, the Southwest
Finland Hospital District and the National Institute
for Health and Welfare. The survey findings indicated that the EHEC outbreak was transmitted through
unpasteurised milk and animal contact.
Listeria outbreak investigated in Vaasa,
cases also found elsewhere in Finland
In July, ten patients at Vaasa City Hospital were diagnosed with gastroenteritis presenting with fever;
the pathogen was confirmed as Listeria monocytogenes
serotype IIa, genotype 225. Moreover, further cases
of invasive listeriosis caused by the same genotype
were discovered in various parts of the country between June and August. The suspected source was a
kind of meat jelly, at the production facility of which
the same rare variant of Listeria was found. After the
manufacture of the meat jelly in question was discontinued, no further cases of listeria caused by genotype
225 were reported.
Cryptosporidiosis outbreaks suspected in
several cities
In October and November, five suspected cases of
a cryptosporidiosis outbreak were reported to the
RYMY system. The first was found at a spa hotel in
Kirkkonummi and the second at a hotel in Tampere.
In these outbreaks, Cryptosporidium parvum was confirmed in patient samples. Three further outbreaks
where cryptosporidium was suspected were investigated in Helsinki and Espoo. These outbreaks involved about 200 people. Possible links between the
outbreaks and the source of the infections were investigated jointly with the local authorities in question,
20
Report 12/2013
National Institute for Health and Welfare
the National Institute for Health and Welfare and the
Finnish Food Safety Authority Evira. All of the reported outbreaks started in October. Tracing the origin of the outbreaks led to the discovery of a certain
kind of Dutch salad as the common factor. Food samples were sent to the European Union Reference Laboratory for Parasites in Italy, but no cryptosporidium
was found. The circumstances in which the salad had
been grown had been favourable for cryptosporidium
contamination because of heavy rains. Moreover, the
importer of the salad had received complaints about
the batch in question because it contained sand.
Chicken cubes suspected of transmitting
outbreak of Salmonella Enteritidis
Between June and October, a total of 40 cases of Salmonella Enteritidis FT 1B were reported in patients
who had not travelled abroad before falling ill. The
cases were spread out across the country. Around the
same time, an identical strain of Salmonella (genotype SENT 117, reduced susceptibility to ciprofloxacin) caused an outbreak at a fast-food restaurant
in Tallinn. A survey revealed that the people who fell
ill had had a chicken salad more often than people in
the control group, and the Finnish Food Safety Authority Evira began to trace the origins of the chicken
foods eaten by the patients. The chicken cubes contained in the chicken salad eaten by some of the patients and in the chicken roll that was found to be
the transmitting food in the Tallinn outbreak came
from the same production facility in China. The investigation has not yet been completed, but a strain
of Salmonella Enteritidis identical to the one found in
the Finnish and Estonian patients and in the chicken
rolls served in Tallinn was found by the British authorities in chicken cubes originating at that production facility. In Finland, salmonella was not found in
the chicken cubes examined in connection with the
outbreak.
Other salmonella clusters
Between mid-June and the beginning of August, a
strain of Salmonella Infantis was isolated in 25 patients who had not travelled abroad before falling ill.
The majority of the samples came from eastern Finland and were susceptible to antimicrobials. Moreover, of the 13 genotyped strains 11 were identical
(SNIF 49). Restaurant food was the suspected source
of the infection.
In July and August, nine cases of Salmonella Group
E (3,10:-:1,5 and genotype E2) were reported. This
strain had caused clusters in the two previous summers too. The infections were traced to a specific res-
Infectious Diseases in Finland 2012
taurant, which closed down pending a renovation
and enhanced cleaning of its premises.
A higher number of cases than normal was also found
for certain other Salmonella serotypes in laboratory
monitoring (S. Isangi in April and May, S. Abony in
October and November, S. Typhimurium FT 120 in
October and November), and for Yersinia enterocolitica serotype O9 in July and August, but no detailed
investigation of these was undertaken.
Campylobacter clusters
The National Institute for Health and Welfare typed
campylobacter strains related to two clusters in western Finland. In both clusters, Campylobacter jejuni
was found. The clusters represented different genotypes, but within each cluster the genotype was identical. The strains found in three children (aged 5, 6
and 16) were associated with drinking unprocessed
milk, while the strains found in seven adults were
associated with the food eaten at a family banquet.
Also, in relation to the water-borne epidemic in eastern Finland, a strain of campylobacter isolated from a
patient was examined, but it turned out to be different from the strains isolated from the water.
Report 12/2013
National Institute for Health and Welfare
21
Infectious Diseases in Finland 2012
Hepatitides
• Hepatitis C was the most prevalent in the age group of 24 to 29; half of the
infections were a consequence of intravenous drug use.
• The number of acute hepatitis B infections was low compared to the late 1990s.
Most of the chronic hepatitis B patients were foreign-born.
• A record low number of cases of hepatitis A.
Hepatitis A
Only eight cases of hepatitis A were reported in 2012
(0.15/100,000), the lowest number ever. Three of the
patients were men, and five were women. The median
age of these cases was 34.5 years (range 2 to 76). Cases
of hepatitis A were found in six hospital districts, the
largest number of them (3) in the Hospital District of
Helsinki and Uusimaa. In three of the cases, the infection was reported as having been acquired abroad
through food or water. Six of the infections had been
contracted abroad and two in Finland. One of the
domestic cases was contracted from foreign visitors
with hepatitis. Hepatitis A cases have remained at a
low level since an epidemic in 2002–2003, probably
because of high vaccination coverage among travellers and risk groups.
Hepatitis B
In 2012, 38 acute hepatitis B infections were reported
(0.7/100,000), 71% of the patients being men and
29% being women. About half of the patients were
Finnish and half foreign. The means of transmission
was given in only one third of the cases: intravenous
drug use in one case and sexual contact in the others. The country of acquisition was known in 60% of
the cases, and the majority (61% of the cases where
the country of acquisition was known) were acquired
abroad.
The number of acute hepatitis B infections reported
annually these days is very low compared to the late
1990s, when the figure was over 200. The low number
of new infections is mainly due to enhanced vaccination coverage. Targeted vaccination of risk groups
was begun in Finland in 1993 and extended in 1998.
Travellers also commonly take the vaccination.
22
Report 12/2013
National Institute for Health and Welfare
The number of chronic hepatitis B infections reported was 229 (4.2/100,000), most of them in the age
group of 25 to 34. The majority (86%) of patients
with chronic hepatitis B were foreigners. Also, the
majority of the infections had been acquired abroad.
The annual number of cases of chronic hepatitis has
been decreasing since it peaked at over 400 in 1996.
This decrease has not been as sharp as that of the
acute cases, however.
Hepatitis C
In 2012, 1,167 new cases of hepatitis C were reported to the NIDR (22/100,000), 67% of the patients
being men and 33% women. The majority (87%) of
these patients were Finnish, and most of them were
in the age group of 24 to 29. The means of transmission was not reported in almost 40% of the cases, and
in about half the means of transmission was reported
as intravenous drug use. The country of acquisition
was known in 56% of the cases. In 90% of the cases
where the country of acquisition was known, the infection was contracted in Finland. The highest incidences were reported in the hospital districts of South
Karelia (34/100,000), Länsi-Pohja (31/100,000) and
North Ostrobothnia (29/100,000).
The annual number of hepatitis C infections peaked at just over 1,900 in 1997. Thereafter, the figure
decreased until 2009 and has remained stable ever
since.
A very high percentage, around 80%, of intravenous
drug users have been found to have hepatitis C antibodies. Because of this, it would be difficult to reduce
the incidence further despite the introduction of needle and syringe exchange programmes.
Infectious Diseases in Finland 2012
The means of transmission is not given in a significant
percentage of the cases. Because hepatitis C is known
not to be readily transmitted through sexual contact,
it is assumed that the cases where the means of transmission is not known must at least for the most part
involve the use of or experimentation with intravenous drugs. The goal is to analyse the ‘not known’
cases more closely to confirm this hypothesis.
120
100
80
60
40
20
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
Injecting drugs
2007
2008
2009
2010
2011
2012
Sex
Figure 10. Acute hepatitis B cases involving intravenous drug use and sexually transmitted infections,
1998–2012 (no. of cases).
450
400
350
300
250
200
150
100
50
0
2001
2002
2003
0–14
2004
15–19
2005
2006
2007
20–24
2008
25–29
2009
30–34
2010
2011
2012
35–
Figure 11. Hepatitis C by age group, 2001–2012 (no. of cases).
Report 12/2013
National Institute for Health and Welfare
23
Infectious Diseases in Finland 2012
Table 2. All cases of hepatitis C according to physicians’ reports, by transmission routes, 2001–2012 (no. of
cases).
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Injecting drugs
826
717
637
615
629
578
468
574
516
596
600
615
Sex
42
45
46
60
62
72
68
74
70
73
86
69
Perinatal
3
3
1
11
5
5
3
11
9
10
11
7
Blood products
20
19
22
18
24
7
21
20
2
9
7
7
Other
31
28
35
31
34
37
28
34
31
38
39
31
Unknown
565
560
524
506
490
469
577
429
422
406
417
450
Total
1487
1372
1265
1241
1244
1168
1165
1142
1050
1132
1160
1179
Hepatitis C, Cases/100,000 population
≤ 10/100 000
11–15/100 000
16–20/100 000
21–25/100 000
> 25/100 000
Figure 12. Incidence of hepatitis C in Finland in 2012, no. of cases per population of 100,000.
24
Report 12/2013
National Institute for Health and Welfare
Infectious Diseases in Finland 2012
Sexually transmitted diseases
• The annual number of gonorrhoea infections continues to grow, setting a record
high for the second time in the 2000s. More than half of the infections were
acquired in Thailand.
• The number of new cases of HIV and AIDS has remained stable for five years.
Chlamydia (CHLAMYDIA TRACHOMATIS)
The number of chlamydia cases reported in the year
under surveillance was 13,458 (249/100,000), 204
cases fewer than in 2011. Women accounted for 59%
of the patients. The highest incidences were reported
on Åland (384/100,000) and in the hospital districts
of Lapland (310/100,000) and Southwest Finland
(288/100,000). The majority of cases were in the age
group of 15 to 24 for women (73%) and 20 to 29 for
men (66%). Patients under the age of 20 accounted
for 32% of the women (2,493) and 14% of the men
(756).
In 2011, for the first time in decades, three cases
of lymphogranuloma venereum (LGV) caused by
Chlamydia trachomatis immunotypes other than B
and D-K (L1-3) were reported. LGV can be typed
from a C. trachomatis nucleic acid positive sample.
Proctitis caused by LGV was found in five men in
Finland in 2012. Three of these infections had been
contracted in Finland.
Gonorrhoea (NEISSERIA GONORRHOEAE)
The annual number of cases of gonorrhoea continued
to grow, to 312 (5.8/100,000). Men accounted for
71% of these. The majority of the cases were in the
age group 20 to 24 for women (34%) and in the age
group 25 to 29 for men (19%). The means of transmission was specified in 72% of the cases; one in three
infections were contracted through sexual contact between men. The incidence was highest in the hospital
districts of Helsinki and Uusimaa (11.9/100,000),
North Karelia (8.2/100,000) and South Karelia
4000
3500
3000
2500
2000
1500
1000
500
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Men, 15–19 years
Men, 20–24 years
Men, 25–29 years
Women, 15–19 years
Women, 20–24 years
Women, 25–29 years
2012
Figure 13. Chlamydia cases in the young adult age groups, 2001–2012 (no. of cases).
Report 12/2013
National Institute for Health and Welfare
25
Infectious Diseases in Finland 2012
Table 3. Gonorrhoea infections acquired domestically and abroad, 2001–2012 (no. of cases).
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Finland
113
100
89
133
133
112
79
90
115
123
106
164
Thailand
17
31
27
38
30
42
44
34
36
45
35
35
Estonia
3
5
2
6
1
-
2
-
-
3
8
6
Russia
34
28
9
7
23
12
6
17
8
8
6
7
Other
26
18
21
21
20
25
22
24
40
33
41
55
Unknown
54
53
41
47
33
45
42
35
40
45
92
45
Total
247
235
189
252
240
236
195
200
239
257
288
312
Table 4. Syphilis infections acquired domestically and abroad, 2001–2012 (no. of cases).
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Finland
32
25
30
22
25
21
56
57
69
36
29
55
Russia
49
22
18
16
22
18
17
26
18
26
22
27
Thailand
1
1
2
1
1
2
6
5
4
5
6
Estonia
2
1
6
1
6
3
4
9
3
9
4
6
Other
12
14
16
12
21
20
29
43
40
50
45
41
Unknown
63
67
62
58
68
67
79
75
67
84
74
66
Total
159
129
133
111
143
130
187
216
202
209
179
201
(6.0/100,000). The country of acquisition was specified in 86% of the cases; 61% of these infections had
been contracted in Finland. The most infections acquired abroad were in Thailand (35 cases).
In 2010, 57% of Gonococcus strains were resistant to
ciprofloxacin (Finres 2010), and accordingly fluoroquinolones should no longer be used for treating
gonorrhoea.
Syphilis (TREPONEMA PALLIDUM)
There were 201 syphilis cases reported in the year under surveillance, 22 more than in 2011 (179). Men
accounted for 62% of the cases, and half of the patients were in the age group 30 to 49. The means
of transmission was given in only 39% of the cases;
half of the male patients had acquired the infection
through sexual contact between men. The incidence
was highest on Åland (10.6/100,000) and in the hospital districts of South Karelia (8.3/100,000) and Kymenlaakso (7.4/100,000). The country of acquisition
was specified in 67% of the cases; in 45% of these, the
infection had been acquired in Finland. Russia was the
most common foreign country of acquisition (27).
26
Report 12/2013
National Institute for Health and Welfare
HIV and AIDS
In the year under surveillance, 159 new cases of HIV
were reported (2.9/100,000), 71% of the patients
being men and 29% women. Foreigners accounted
for 45% of all cases, and agewise the largest number
of cases was in the age group 25 to 39. The majority of HIV infections were acquired through sexual
contact: 43% through heterosexual contact and 26%
through male homosexual contact. Intravenous drug
use accounted for only 3%, and in 23% of the cases the means of transmission was not known. More
than half (55%) of the infections had been acquired
abroad and 21% in Finland; in 25% of the cases the
country of acquisition was not known. No significant
changes have occurred in the annual number of new
cases, means of transmission or gender distribution
over the past five years.
By the end of the year, the total number of new HIV
infections ever reported in Finland was 3,069. The
number of surviving infected persons has increased
due both to new cases and to improved medical treatment decreasing the number of deaths from AIDS.
Data in the NIDR indicates that at the end of 2012
there were about 2,400 HIV-positive people in Finland who were aware of their condition.
Infectious Diseases in Finland 2012
The number of infections acquired through heterosexual contact was 68, nearly half of them reported in foreigners. The majority of infections acquired through
heterosexual contact were acquired abroad, 86% (including both Finns and foreigners and excluding cases
where the country of acquisition was not known).
The number of infections from homosexual encounters between men was 47. The majority (87%) of
these patients were Finnish. About half of these infections were acquired in Finland and half abroad.
The incidence and prevalence of HIV in this group
are significantly higher than in the general population on average.
Only five cases were reported where the infection was
acquired through intravenous drug use. All of the
patients were foreigners, and the infection had been
acquired abroad. Effective preventive measures have
kept infections from intravenous drug use in Finland
at a low level following the HIV epidemic at the turn
of the millennium.
One case of mother-child infection was reported
in the year under review; this child had been born
abroad. A total of 15 mother-child HIV infections
have been found in Finland in the 2000s, all but one
of them of foreign origin. Mother-child transmission
can be effectively prevented with medication during
pregnancy.
There was one reported case of HIV infection possibly caused by a blood transfusion. The transfusion
had been performed abroad. There have been no re-
ported cases of infection through blood products in
Finland since HIV testing of donated blood began
in 1985.
The means of transmission was not reported in 23%
of the cases. In more than 70% of these ‘not known’
cases the patient was a foreigner, and the principal
reason for the lack of the means of transmission was
the absence of a physician’s report.
Foreign patients accounted for 70 new cases of HIV,
representing more than 20 nationalities. The principal mode of transmission was a heterosexual encounter. On the other hand, the means of transmission
was not known in almost 40% of the cases.
In the year under review, 17 new cases of AIDS were
reported: 11 of the patients were Finns and six were
foreigners. The number of HIV-positive patients who
died during the year was 14, the cause of death being
AIDS in five cases. Thanks to effective medication,
AIDS is no longer the principal cause of death for
HIV-positive persons. By the end of 2012, 304 persons in all had died from AIDS in Finland.
The CD4 value was reported in 74% of the cases.
As in early years, the percentage of late detection of
infections (CD4 lower than 350) was high: the diagnosis was late for Finns in 44% of cases and for foreigners in 62% of cases. Late diagnosis weakens the
treatment prognosis and increases the possibility of
other infections. Changes in primary resistance were
found in 4% of the HIV virus strain samples, which
by European standards is low.
100
90
80
70
60
50
40
30
20
10
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Heterosexual transmission
Injecting drug use
Mother-to-child transmission
Men having sex with men
Blood products
Not notified
2012
Figure 14. HIV cases by transmission route, 2001–2012 (no. of cases).
Report 12/2013
National Institute for Health and Welfare
27
Infectious Diseases in Finland 2012
Antimicrobial resistance
• The number of ESBL E. coli blood culture findings continued to grow.
• Most of the strains producing carbapenemase were of foreign origin, often from
India.
• There was no increase in the number of MRSA cases on the previous year; there
were fewer blood culture findings.
• Pneumococcal infections caused by vaccine serotypes decreased by a third
compared to the years preceding the introduction of the vaccine; this change has
been the most marked in the age group of under 2 years.
MRSA
In 2012, 1,283 cases of methicillin-resistant Staphylococcus aureus (MRSA) were reported, about the
same number as in the year before (2011: 1,327). Of
these, 20% (2009–2010: 22–25%), were diagnosed
only from samples taken from the nose or the nostrils. There were fewer MRSA blood culture findings
than in the previous year (2012: 30; 2011: 42). Of
the MRSA blood culture findings, 10 (33%) were
found in the Tampere Region (2.0/100,000) and four
(13%) in the Helsinki and Uusimaa Hospital District (0.3/100,000); other hospital districts reported
nil to three cases each, totalling 16. Most (17 out of
30) of the invasive cases occurred in patients older
than 65, and two in children. As earlier, the hospital
districts of Pirkanmaa and of Helsinki and Uusimaa
reported the highest total figures. The incidence was
highest in the Pirkanmaa and Länsi-Pohja Hospital
Districts. The percentage of findings in patients aged
over 75 was 37%, slightly less than in the previous
year (44%). The number of MRSA cases in children
increased (94–127).
An MRSA strain was typed in more than 1,300 individuals. There were 186 different spa types in the
MRSA strains (2011: 160). The most common spa
types were the same as in previous years, but the
ranking of the two most common changed from the
previous year. The most common spa types in 2012
were: t172 at 17% (2011: 18%), t067 at 15% (2011:
28%), t008 at 12% (2011: 8%), t002 at 4% (2011:
4%) and t032 at 3% (2010: 3%). t172 was reported
in 17 hospital districts, while t067 occurred in seven
hospital districts, most commonly in Pirkanmaa.
28
Report 12/2013
National Institute for Health and Welfare
In the first half of the year (until 30 June), t008 and
t002 strains were also typed using pulse field gel electrophoresis (PFGE). Both spa types were sub-divided
into several PFGE types. Of the t008 strains typed
with PFGE, almost half (41%) were of PFGE type
FIN-25, which is an internationally known strain of
MRSA originally found in community (USA 300),
and one in five (19%) were of PFGE type FIN-7.
Local clusters (MRSA strain isolated in more than 10
patients) also occurred in the North Karelia (t721),
Helsinki and Uusimaa (t657), Pirkanmaa (t1012)
and Southwest Finland (t688) Hospital Districts.
The most common spa type among patients over 75
was t067 (27%; 2011: 37%). The most common
spa types among children under the age of 16 were
t172 (18%), t657 (9%) and t008 (8%). In 2011 too,
t172 was the most common spa type among children
(19%), followed by t233 (11%) and t002 (9%).
An MRSA strain isolated from the blood was typed
in 20 individuals. Six of these were of spa type t067,
five of spa type t008, and the remainder (9/20) featured eight different spa types.
VRE
The number of reported cases of vancomycin-resistant
enterococcus (VRE) decreased on the previous year
(2012: 93; 2011: 128). The most cases were reported
by the hospital districts of Kymenlaakso (30), North
Ostrobothnia (17), Helsinki and Uusimaa (10),
Southwest Finland (9) and Länsi-Pohja (9) (75/93);
analysed by age, the majority of cases was in the age
Infectious Diseases in Finland 2012
700
600
500
400
300
200
100
0
Central Finland
Southern
Vaasa
Bothnia
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
Päijät-Häme
Kymenlaakso
Southern
Karelia
Southern
Savo
Eastern
Savo
Northern
Karelia
Northern
Savo
Figures 15a and 15b. MRSA cases by hospital district, 2001–2012 (no. of cases).
group of over 60 (72/93). In other hospital districts,
the number of findings varied from 0 to 4. Seven of
the findings were blood culture findings (2011: 4).
VRE findings were typed in 83 individuals. Most of
the findings represented the E. faecium (68/83) species and the vanB type (76/83). However, pulse field
gel electrophoresis (PFGE) revealed a new epidemic
strain in the Kymenlaakso Hospital District, VRE
XIII, of the E. faecalis species. This strain was isolated
in 12 patients. The most common strain type in the
year under surveillance was VRE XI (17/83), which
caused a cluster of 14 cases, also in the Kymenlaakso
Hospital District. The most common strain type in
2011 had been VRE X, which had spread in the Lapland Hospital District; in the year under surveillance,
13 further cases were reported in the North Ostro-
bothnia Hospital District. The North Ostrobothnia
Hospital District also reported nine VRE VII cases.
The remainder of the typed strains (34/83) were isolated (unique 29/83) or findings of VRE V (1/83),
VRE VIII (2/83) or VRE IX (1/83).
ESBL
Since the beginning of 2008, Escherichia coli and
Klebsiella pneumoniae exhibiting reduced susceptibility or resistance to third-generation cephalosporins
(I for intermediate and R for resistant, respectively)
have been reported to the NIDR. The majority of
these bacteria are strains producing ESBL-enzyme
that split penicillin and cephalosporins.
Report 12/2013
National Institute for Health and Welfare
29
Infectious Diseases in Finland 2012
Table 5. MRSA findings and their percentage of S. aureus blood culture findings, 1995–2012 (no. of cases and %).
All
MRSA findings
S. aureus
blood culture findings
MRSA blood culture findings
and the methicillin resistance
of S. aureus (%)
1995
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)
2011
1327
1487
42 (2,8)
2012
1283
1488
30 (2,0)
Total
15189
18664
337 (1,8)
Table 6. E. coli findings with reduced susceptibility to third-generation cephalosporins (possible ESBL, extended-spectrum β-lactamase) and ESBL percentage, 2008–2012 (no. of cases and %).
2008
ESBL-findings
E. coli blood culture findings
ESBL E. coli blood culture findings and
percentage of ESBL of E. coli
1707
2813
42 (1,5)
2009
2158
2991
77 (2,6)
2010
2522
3211
112 (3,5)
2011
3119
3473
150 (4,3)
2012
3230
3448
179 (5,2)
Total
12736
15936
560 (3,5)
In the year under surveillance, most of the ESBL findings were E. coli (3,230; 2011: 3,119), with a small
minority of K. pneumoniae strains (204; 2011: 244).
ESBL E. coli findings were made in all age groups –
almost 75% in women and over half in patients aged
65 years or more. The majority of diagnoses (69%,
2,213/3,230) were made from urine. The largest
number of cases was found in the Hospital District
of Helsinki and Uusimaa (908, 59/100,000), but the
incidence was highest in the Lapland, Kymenlaak-
30
Report 12/2013
National Institute for Health and Welfare
so and Päijät-Häme hospital districts (108, 88 and
86/100,000, respectively). There were more blood
culture findings than in the previous year (2012:
179; 2011: 150) (percentage of ESBL E. coli in blood
cultures was 179/3,448 or 5.2%; 2011: 4.3%). The
majority of the findings were made in the Hospital District of Helsinki and Uusimaa. However, the
incidence in blood culture findings was highest in
the hospital districts of Kanta-Häme, Lapland and
Vaasa.
Infectious Diseases in Finland 2012
Table 7. K. pneumoniae findings with reduced susceptibility to third generation cephalosporins (possible
ESBL, extended-spectrum β-lactamase) and ESBL percentage, 2008–2012 (no. of cases and %).
ESBL findings
K. pneumonia
blood culture findings
ESBL K. pneumonia
blood culture findings and
percentage of ESBL of K. pneumonia
2008
111
418
4 (1)
2009
154
480
6 (1,3)
2010
184
504
16 (3,2)
2011
244
449
16 (3,6)
2012
204
581
14 (2,4)
Total
897
2432
56 (2,3)
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 65%. The majority of diagnoses (62%, 126/204) were made from
urine. The largest number of cases was recorded in
the hospital districts of Helsinki and Uusimaa (45)
and North Ostrobothnia (21), while the incidence
was highest in the Lapland and Päijät-Häme hospital
districts. There were 14 blood culture findings (2011:
16) (percentage of ESBL in K. pneumoniae blood cultures was 14/581 or 2.4%; 2011: 3.6%).
Strains producing ESBL and carbapenemase
In 2012, genes encoding extended-spectrum betalactamases (ESBL) or carbapenemase were specified
in 230 bacterial strains. The strains had been collected for epidemic control or for confirmation of thirdgeneration cephalosporin-resistance or a carbapenemase gene. The figure includes 230 E. coli and 14
K. pneumoniae strains.
The most common ESBL gene was CTX-M, as in
earlier years. In addition to ESBL genes proper, plasmid-mediated ampC genes were found in E. coli
strains. Seven of the strains studied had a carbapenemase gene. Three strains of E. coli had an NDM
gene. These strains were all of different sequence types
(ST405, ST410, ST224), and in all cases the patient
had some contact with a foreign country (India, Nepal). Four strains of K. pneumoniae studied had a carbapenemase gene: two had KPC, one had NDM and
one had OXA-181. The strains with a KPC gene were
of sequence types ST258 and ST11; the strain with an
OXA gene was of sequence type ST14; and the strain
with an NDM gene was of sequence type ST1012. A
KPC-positive strain of sequence type ST258 was iso-
lated from a patient for whom a foreign contact could
not be confirmed. For all other patients, a connection
with a foreign country was established (ST11: China;
ST14 and ST102: India).
Thus, as in the previous year, a major percentage of
bacterial strains with carbapenemase was of foreign
origin, but strains of Finnish origin were also found.
However, sequence typing and epidemiological data
show no indication so far of local epidemics.
Invasive pneumococcal
disease (STREPTOCOCCUS PNEUMONIAE)
In the year under surveillance, there were 751 reported cases (14/100,000) of invasive pneumococcal disease confirmed by blood or cerebrospinal fluid culture (2011: 779, 14/100,000). As in previous
years, the incidence was higher among men than
among women (15 vs. 13/100,000). There was considerable regional variation between hospital districts
(10–28/100,000), which may be due to differences in
how actively blood cultures are taken. Children under the age of 5 accounted for 4.3% of the patients.
Almost half of the cases (46%) were found in the age
group of over 65. There were 22 cases reported on the
basis of nucleic acid detection. No serotype data are
available for these cases, and they are not included in
the statistics.
In the year under surveillance, 729 cases of pneumococcal disease confirmed by culture were serotyped.
The cases were divided into 37 serotypes or groups
(Figure 16). As in previous years, the most common
serotype was 14 (14%), followed by 3 (10%), 22F
(10%) and 4 (8%). Since 2010, children have been
Report 12/2013
National Institute for Health and Welfare
31
Infectious Diseases in Finland 2012
120
100
80
60
40
20
0
14
3
22F
4
23F
7F
9N
19A
6B
19F
6C
18C
11A
9V
6A
23A
Other
Unknown
Figure 16. Serotypes of Streptococcus pneumoniae findings in blood and cerebrospinal fluid, 2012 (no. of
cases). The column ‘Other’ includes serotypes that caused fewer than 10 cases.
Table 8. Streptococcus pneumoniae findings in blood and cerebrospinal fluid by age and vaccine serotype,
2008–2012 (no. of cases).
PCV10 vaccine serotypes
Non-vaccine serotypes
<2
2−4
5−64
65−
Yht.
<2
2−4
5−64
65−
Total
2008
49
26
305
198
578
13
6
177
118
314
34
2009
47
26
301
166
540
12
4
149
117
282
33
2010
51
35
253
167
506
8
5
155
123
291
39
2011
34
16
232
150
432
11
11
172
145
339
8
2012
8
15
192
147
362
7
2
178
180
367
21
given a 10-valent pneumococcal conjugate vaccine
(PCV10) as part of the national vaccination programme at the ages of 3, 5 and 12 months. The effectiveness of the vaccination programme is being
monitored, and vaccination data for all children born
on or after 1 June 2010 who contract a serious case of
pneumococcal disease are investigated.
In the year under surveillance, the number of serious
cases of pneumococcal disease caused by the PCV10
vaccine serotypes (1, 4, 5, 6B, 7F, 9V, 14, 18C, 19F,
23F) decreased by about a third compared to the years
before the vaccine was introduced (2008–2009). The
greatest relative change was seen in the age group of
under 2, where cases of pneumococcal disease all but
vanished compared to previous years (Table 8). All
32
Unknown
Report 12/2013
National Institute for Health and Welfare
cases that did occur in this age group, except for one,
involved children who had not yet been vaccinated
because of their age or whose parents had not allowed
them to be vaccinated. In one case, a child had received one dose of the vaccine at the age of 3 months
just over a month before contracting a disease where
a vaccine serotype was the pathogen. The number
of cases caused by other than the PCV10 serotypes
remained stable or decreased slightly, except in the
age group of over 65, where the number of cases increased compared with the years before the vaccine
was introduced.
Antimicrobial sensitivity was determined for 754
strains of invasive pneumococcus (Table 9). Strains
with reduced susceptibility to penicillin (MIC > 0.06
Infectious Diseases in Finland 2012
Table 9. Antimicrobial resistance of Streptococcus pneumoniae findings in blood and cerebrospinal fluid, 1998-2012
(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
2011
779
780
26,8
21,9
2,8
2012
751
754
22,2
27,7
5,0
I – reduced susceptibility: R – resistant; Multidrug resistance – strains simultaneously resistant to penicillin (I+R), erythromycin (R) and tetracycline (R)
mg/L) accounted for 28% of the strains, and strains
completely resistant to penicillin (MIC > 2 mg/L)
accounted for 1%. The percentage of macrolide-resistant strains continued to decrease; 22% of invasive
pneumococcal strains were resistant to erythromycin. Multiresistant strains (PEN IR-ERY R-TET R)
accounted for 5% of the strains. No strains resistant to levofloxacin (MIC > 2 mg/L) were found in
2012. There were two strains resistant to ceftriaxone
(MIC > 2 mg/L) (0.3%). In general, the changes in
the susceptibility of invasive pneumococcus strains
were minor when compared with 2010 findings.
Report 12/2013
National Institute for Health and Welfare
33
Infectious Diseases in Finland 2012
Tuberculosis
• There were fewer cases of tuberculosis than in earlier years, and those who
contracted the disease were younger than before.
• Just over one quarter of patients contracting tuberculosis were foreigners; most
of the patients were aged between 15 and 44.
• Finland’s first strain of extensively drug-resistant tuberculosis was found;
otherwise, the antimicrobial susceptibility situation remains good.
• Pulmonary tuberculosis treatment outcomes were good in 2010, an improvement
on previous years.
Tuberculosis
(MYCOBACTERIUM TUBERCULOSIS)
previous year (251). According to physicians’ reports,
23 patients (8%) had a previous history of tuberculosis diagnosed after 1950, when anti-tuberculosis
medication became available.
Tuberculosis monitoring
The increase in the overall number of tuberculosis
cases in Finland in 2007 and 2008 compared to 2006
can be explained by the introduction in 2007 of the
broader EU definition of tuberculosis cases. The annual numbers of cases confirmed by culture are comparable throughout the monitoring period. The annual number of cases confirmed by culture remained
stable from 2007 to 2011 except in 2009, when an
exceptionally large number of cases in foreigners was
recorded; in 2012, however, the figure decreased.
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 only included if the diagnosis was
based on histology or a case of pulmonary tuberculosis was confirmed by positive sputum staining for
tuberculosis bacilli.
Since 2007, Finland has followed the case definition
of the European Union’s infectious disease surveillance for tuberculosis: in addition to cases fulfilling
the criteria mentioned above, the statistics also include cases in which a physician suspected tuberculosis on the basis of clinical evidence and decided to
give full tuberculosis treatment even though the infection was not confirmed by microbiological tests or
histology. The new grounds for compiling statistics
do not affect the number of cases confirmed by laboratory tests or histology.
Incidence of tuberculosis 2012
There were 275 cases of tuberculosis (5.1/100,000),
51 cases fewer (16%) than in the previous year (326,
6.1/100,000). Of these, 196 (71%) were pulmonary
tuberculosis, of which 83 (42%) produced a positive
sputum stain test. There were 224 cases of tuberculosis confirmed by culture (81%), 27 fewer than in the
34
Report 12/2013
National Institute for Health and Welfare
The distribution of cases by age group was as follows:
under 15, 5 (2%); 15 to 29, 45 (16%); 30 to 44, 48
(18%); 45 to 59, 42 (15%); 60 to 74, 54 (20%); and
over 75, 81 (30%). In half of all cases the patients
were over 60 years of age, and most of them were
born in Finland; their cases involved a reactivation
of a latent infection contracted decades ago. Population reduction among the age groups in whose youth
the incidence of tuberculosis in Finland was high has
led to a notable decrease in the average age of tuberculosis patients between 2000 and 2012, from 63.9
to 55.9 years. No increasing trend has been found in
children aged under 5 after the change to the vaccination programme in 2006.
The patient was reported to be foreign in 77 cases
(28%), i.e. born abroad and assumed to have other
than Finnish citizenship unless the data indicate otherwise. The distribution of these cases by age group
Infectious Diseases in Finland 2012
Table 10. Incidence of tuberculosis and percentage of culture-confirmed cases in Finland, 1995–2012 (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
2011
236
4,4
86
1,6
90
1,7
326
6,1
251
77
2012
196
3,6
83
1,5
79
1,5
275
5,1
224
81,5
Table 11. Cases of tuberculosis in foreigners, 1995–2012 (no. of cases and %).
Pulmonary tuberculosis
Cases in
foreigners
Proportion
of foreigners
(%)
Other tuberculosis
Cases in
foreigners
All cases
Proportion
of foreigners
(%)
Cases in
foreigners
Proportion
of foreigners
(%)
1995
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
2011
49
20,8
31
34,4
80
24,5
2012
54
27,6
23
29,1
77
28,0
Report 12/2013
National Institute for Health and Welfare
35
Infectious Diseases in Finland 2012
was as follows: under 15, 2 (3%); 15 to 29, 29 (38%);
30 to 44, 32 (42%); 45 to 59, 7 (9%); and over 70,
7 (9%). Among these there were 54 cases (70%) of
pulmonary tuberculosis and 23 cases (30%) of other
forms of tuberculosis. Information on the patient’s
country of birth or citizenship was missing in 17 cases (6%).
to the Jazz cluster (SIT42) that has been spreading in
the Helsinki metropolitan area for some time. There
was a school outbreak caused by the SIT149 genotype in Turku.
In 6 (2%) of the tuberculosis cases reported in 2012,
the patient also had an HIV infection. Four of these
were new HIV infections reported in 2012, and two
had been reported earlier. Five of the cases were foreign in origin.
Tuberculosis strain susceptibility in 2012
Tuberculosis genotyping findings 2012
All new M. tuberculosis strains were genotyped using
the internationally standardised spoligotyping and
MIRU-VNTR methods.
Spoligotype SIT53 remains the most common genotype in Finnish strains of M. tuberculosis. It can be
analysed into several clusters using the MIRU-VNTR method. Two new SIT53 clusters were found in
2012 in addition to those found earlier. One new case
emerged in the SIT53 cluster that had spread among
socially marginalized people in the Tampere region.
The total number of strains genotyped in this cluster at the National Institute for Health and Welfare
is now 25. One new case was added to the SIT914
cluster associated with hospital environments in the
Helsinki and Uusimaa Hospital District, bringing
the total to 17 cases. One new case was also added
Genotyping also confirmed that three patient samples had got mixed up.
The susceptibility of Mycobacterium tuberculosis strains
in Finland remains good. Of all cultured strains, 92%
had full susceptibility; however, an extremely drugresistant (XDR) strain of tuberculosis was found in
a man in southern Finland. This strain is resistant to
all first-line drugs used for tuberculosis treatment and
also to two second-line drugs. Two other cases of multi-drug resistant (MDR) tuberculosis were reported
during the year, one in a seven-year-old foreign-born
girl and the other in a foreign-born man.
Tuberculosis outcome surveillance in
2007–2010
Table 12 shows the distribution of treatment outcomes between 2007 and 2010. The domain consists
of cases of pulmonary tuberculosis confirmed by culture, genetic replication or mycobacterial staining.
Cases where the pathogen is an MDR strain are reported separately and are not included in Table 12.
An outcome evaluation is performed 12 months after the case is registered. The outcome evaluations for
2010 were further complemented after the previous
Table 12. Results of outcome evaluation for treatment of microbiologically confirmed pulmonary tuberculosis, 2007–2010 (no. of cases and %).
Cases under surveillance
2007
2008
2009
2010
200
191
241
187
144 (72 %)
140 (73 %)
167 (69 %)
149 (80 %)
Treatment outcome
Favourable
Cured
85
89
84
94
Treatment completed
59
51
83
55
Non-favourable
41 (21 %)
37 (19 %)
44 (18 %)
22 (12 %)
Deceased
38 (19 %)
33 (17 %)
41 (17 %)
18 (10 %)
1
1
0
0
Treatment failure
Interrupted treatment
Missing
Transfer
36
2
3
3
4
15 (7 %)
14 (7 %)
30 (12 %)
16 (8 %)
2
2
13
4
Treatment continues at 12 months
7
9
9
8
Notified, as not known
1
3
2
1
Notification missing
5
0
6
3
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National Institute for Health and Welfare
Infectious Diseases in Finland 2012
year’s report was published. The data for the outcome
evaluation for 2011 are not yet available.
The treatment outcome was good in 80% of the cases
in 2010, slightly higher than in earlier years. 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.
Mortality (before beginning treatment or during
treatment) was 10% in 2010, clearly lower than in
earlier monitored years. This is probably mainly because of the decreasing average age of tuberculosis
patients.
Report 12/2013
National Institute for Health and Welfare
37
Infectious Diseases in Finland 2012
Other infections
• Group B meningococcus was contracted by young people and Group Y
meningococcus by older people.
• The number of measles cases decreased. Those who contracted measles had
travelled in Thailand or Turkey.
• The number of tularemia cases was triple that in the previous year, with
the highest incidence in the hospital districts of Central Ostrobothnia, South
Ostrobothnia and Vaasa.
• There were more cases of Pogosta disease than in the previous year, the most
cases being reported in North Karelia and eastern Savo.
• Dengue fever infections among tourists have increased in recent years.
• The number of blood culture findings among persons aged 65 or over continued to
increase.
• An outbreak of Group A streptococcus in Satakunta was caused by emm-type 1,
associated with a severe form of the disease
Haemophilus (HAEMOPHILUS INFLUENZAE)
In the year under surveillance, there were 81 reported infections caused by the Haemophilus influenzae
bacterium, diagnosed in blood or cerebrospinal fluid,
more than half as many again as in recent years on
average and slightly more than in 2011 (66). Almost
half of the cases (48%) were found in the age group
of over 75.
All cases were diagnosed through culture findings.
The majority of these (73, 90%) were caused by unencapsulated strains of Haemophilus influenzae, as in
earlier years. Serotype b caused an infection in one
adult and three children aged under one year (6, 8
and 11 months), and serotype f caused an infection
in three adults and one child. No infections caused by
serotypes a, c, d or e were found.
The adult who contracted serotype b belonged to an
age group in whose childhood Hib vaccine was not
yet included in the vaccination programme. Two of
the children who fell ill were born abroad. The parents of one of them refused to have their child vaccinated both abroad and in Finland; the other had
never attended a child care clinic. The third child
who fell ill had an immune deficiency condition and
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National Institute for Health and Welfare
had received the 3-month and 5-month vaccine doses, but fell ill at the age of 11 months, before the third
dose. Although the vaccination programme designed
to limit carriage of the bacteria in the throat has succeeded in limiting the circulation of serotype b in the
population, rare cases occur in children with incomplete vaccination coverage.
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)
In the year under surveillance, the number of meningococcus infections detected in blood or CSF totalled
33 (0.61/100,000), which is about the same as in the
previous three years (Table 13). Of these, 30 were diagnosed through a culture finding and three through
nucleic acid detection. All isolated strains were sero-
Infectious Diseases in Finland 2012
Table 13. Meningococcal infections by serogroup, 2001–2012 (no. of cases).
Group A
Group B
Group C
Group Y
Group W135
Unknown
Total
2001
0
30
11
2
3
2
48
2002
0
34
9
4
1
3
51
2003
0
36
6
4
1
2
49
2004
0
28
5
6
0
2
41
2005
0
29
5
4
2
4
44
2006
0
33
1
3
0
3
40
2007
0
38
5
1
0
1
45
2008
0
29
8
5
0
1
43
2009
0
19
8
2
0
0
29
2010
0
14
4
13
1
3
35
2011
0
19
6
7
1
1
34
2012
0
17
3
8
1
4
33
grouped and genotyped: 17 (57%) were of serogroup
B, 8 (27%) of serogroup Y, 3 (10%) of serogroup C
and 1 (3%) of serogroup W135. One strain was not
serogrouped.
The age distribution of the cases was much the same as
in previous years: five in the age group 0 to 4, two in
the age group 5 to 14, nine in the age group 15 to 19,
and 17 in the age group over 20. Group B meningococcus mainly causes infections in young adults, while
group Y cases tend to concentrate in older age groups.
In 2012, the Swedish Institute for Communicable
Disease Control (SMI) reported a considerably elevated number of meningococcal infections due particularly to the increased incidence of serogroup Y.
Genotyping showed that the group B strains were
divided into 13 types. The most common type was
B:P1.7-2,4:F1-5, which caused an infection in four
adults in various parts of the country. In the previous year, the same strain infected ten persons. The
strain belongs to a virulent clone that has spread
worldwide. It caused a persistent epidemic in New
Zealand in the 1990s and has since caused clusters
of infections in Europe too. Five types of group Y
strains were identified. The most common type was
Y:P1.5-1,10-1:F4-1, which caused an infection in
three young adults. Two of the patients were from the
Helsinki metropolitan area and one from the KantaHäme Hospital District. The group C strains were
divided into two types.
In September and October, a cluster of group B
meningococcal infections was reported in North
Karelia. However, genotyping showed that all three
cases were caused by different strains.
In sporadic cases of meningococcus, all persons in
close contact with the patient except for health care
personnel should be given prophylactic medication
and also a vaccination, if infection from that strain
can be prevented by vaccination. Finland has vaccines
against meningococcus serotype groups A, C, W135
and Y. A new vaccine against group B meningococcus
strains is coming onto the market.
MMR diseases (measles,
mumps, rubella)
In the year under surveillance, four cases of measles
were reported. This was clearly fewer than in the previous year (27). The patients were aged between 13
and 40. All except one had not been vaccinated. Prior to falling ill, they had travelled in Thailand and
Turkey. The measles viruses brought from Thailand
were of the D8 genotype and were identical to viruses
isolated in Thailand. In Europe as a whole, measles
viruses of the D8 genotype were the most commonly
isolated genotype in 2012.
Three cases of mumps were reported in the year under
surveillance. The patients were aged between 12 and
43. Prior to falling ill, they had travelled in Morocco,
Cyprus and Greece. Two of the patients had received
two MMR vaccinations, one of them having received
two doses of the Triviraten® vaccine. The vaccination
history of the third patient is not known. The Triviraten® vaccine was used on children highly allergic to
eggs in Finland between 1992 and 2004. The protection it provides against mumps is lower than that
provided by other MMR vaccines. It is recommended
that those vaccinated with the aforementioned vacReport 12/2013
National Institute for Health and Welfare
39
Infectious Diseases in Finland 2012
Puumala virus
Cases/100,000 population
0–25/100 000
26–50/100 000
51–75/100 000
76–100/100 000
Figure 17. Cases of Puumala virus by hospital district, 2012 (no. of cases per 100,000 population).
cine should get a booster shot of the currently used
MMR vaccine.
No cases of rubella were recorded in Finland in the
year under review.
Varicella virus
The number of varicella findings reported to the
NIDR was slightly higher than in the previous year,
489 (2011: 435). Of these findings, 208 were diagnosed by antigen detection, 117 by nucleic acid detection and 174 by serological diagnostics. There were
55 (11%) reports based on a diagnosis from CSF, involving the finding of a varicella nucleic acid in 49
cases, a varicella antigen in one case and varicella antibodies in five cases.
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The patients were aged between 0 and 94. Childhood varicella or chicken pox is a very common
disease, with an estimated 57,000 cases in Finland
every year. It is mostly diagnosed clinically and does
not even lead to a health care in the majority of the
cases. By contrast, herpes zoster, or shingles, causes
far more use of health care services especially in the
elderly, and this can be seen in the age distribution
of virus findings. The incidence was 9/100,000 on
average, being clearly the highest in the age group
over 70: 16/100,000 in the age group 70 to 74 and
19/100,000 in the age group over 75. Currently, varicella vaccination is recommended to everyone aged
13 or over who has not had chicken pox. The National Institute for Health and Welfare is recommending
that varicella vaccination be incorporated in the national vaccination programme.
Infectious Diseases in Finland 2012
Puumala virus
Tick-borne encephalitis (TBE)
In the year under surveillance, 841 cases of Puumala virus were reported (16/100,000), which is only
about half of the number in the previous year. The
annual 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 previous peaks occurred in 2002, 2005
and 2008, with a slight increase also in 2011. Of the
patients, 59% were men, and most patients were of
working age. There were 31 (4%) under 20 years
of age. The incidence was highest in the Etelä-Savo
Hospital District (58/100,000) and the Pohjois-Savo
Hospital District (54/100,000).
The number of TBE antigen findings reported in the
year under surveillance was 43, which is roughly the
same as in previous years; however, only 39 patients
presented with symptoms consistent with tick-borne
encephalitis. In one patient, the diagnosis was made
from CSF using nucleic acid detection.
Positive TBE findings were reported between May
and October, the largest number being reported in
July. The patients who contracted TBE were aged between 4 and 82. Six of them were from Åland and the
remaining 33 from elsewhere in Finland. All residents
of Åland have been entitled to a TBE vaccination free
of charge since 2006. All of the TBE patients from
Åland in 2012 had not been vaccinated. The vaccination programme on Åland should be enhanced.
Place of acquisition
TBE virus found in ticks
Figure 18. Cases of TBE by location of acquisition, 2012, and TBE virus findings in ticks, 1996–2011.
Report 12/2013
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41
Infectious Diseases in Finland 2012
In order to identify the place of acquisition, the National Institute for Health and Welfare interviewed
patients who had been diagnosed with TBE in 2012
and/or studied their patient records. It was found
that ten (25%) of the infections were acquired in the
Turku archipelago, eight (20%) on Åland, seven in
Simo, four in the Kotka archipelago, two in Lappeenranta, one in the Sipoo archipelago, one in Kemi, one
in Hirvensalmi, one in Vaasa and one in Kitee. Three
Finnish nationals were infected in Estonia. In one
case, the location of acquisition remained unclear.
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, especially if this happens in known high-risk areas. 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)
In the year under surveillance, 233 laboratory-confirmed cases of tularemia were reported (incidence
4.3/100,000); this was three times higher than in the
previous year. The largest number of tularemia cases
(65) was found in the South Ostrobothnia Hospital District. The incidence was highest in the hospital districts of Central Ostrobothnia (43.9/100,000),
South Ostrobothnia (32.7/100,000) and Vaasa
(19.7/100,000). Infections were diagnosed in all age
groups, most frequently in the age group 50 to 64. As
is typical, the majority of the cases were diagnosed in
August and September.
The annual incidence of tularemia varies greatly (0.5
to 18/100,000 since 1995), and the epidemics, which
occur with a cycle of a few years, tend to be local.
Tularemia bacteria are mainly transmitted by insect
bites, which explains why the incidence of the disease
peaks in late summer. So far, it is not known which
local ecological circumstances might explain the differences in incidence between hospital districts.
Pogosta disease (SINDBIS VIRUS)
There were 189 cases confirmed with antibody testing, clearly more than in the previous year (2011: 63).
The incidence was highest in the hospital districts of
North Karelia and Itä-Savo (19 and 18/100,000, respectively). Of the patients, 152 (80%) were of working age, aged 20 to 64, and 114 (60%) were women.
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The majority of the cases, 161 (85%), were diagnosed
between July and September.
The Sindbis virus is principally borne by mosquito
species prevalent in late summer. Temperatures in
early summer and rainfall and snowfall in the previous winter significantly affect incidence. Waterway
regulation, other local ecological and socioeconomic
factors together with cyclical variation in available
animal reservoirs (forest game birds) may also play a
role in the incidence of the disease in Finland. Cases
of Pogosta disease tend to cluster in the period from
late July to September.
A Sindbis infection that presents with symptoms
is more common in Finland than elsewhere in the
world. The virus has an incubation period of one
week, after which the infection presents with a fever commonly accompanied by rash and muscle and
joint symptoms. The joint pain may persist for years
in some patients, and is not always easy to associate
with Pogosta disease. Genetic susceptibility is probably a factor both in contracting the infection and in
the presentation of symptoms.
Pogosta disease has followed a regular seven-year 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 the year under surveillance, 1,587 cases of borrelia
were reported, roughly on a par with previous years
(2010: 1,442; 2011: 1,662). Of these reports, ten
were based on nucleic acid detection and 1,577 on a
serological test. The incidence in the whole country
was 29/100,000 on average, but once again there was
significant regional variation. As before, the incidence
was highest on Åland (1,904/100,000), accounting
for 540 cases, or one third of all diagnosed borrelia infections in Finland. 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; 52% of the patients were women.
Rabies
Doctors are required to report cases where risk assessment has led to the start of rabies vaccination treatment after exposure. In 2012, 56 reports were made.
A further eight suspected cases were reported in the
Helsinki and Uusimaa Hospital District in which the
exposure had occurred in 2011. There were 22 patients who had been exposed abroad: nine in Thai-
Infectious Diseases in Finland 2012
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 19. Borrelia cases by hospital district, 2012 (no. of cases/100,000).
land and a few each in Indonesia, India and Russia.
In most of the cases contracted abroad, exposure consisted of dog bites. There were 34 reported cases of
exposure in Finland: 13 (38%) involving bat contact
and 13 (38%) involving a dog bite; in eight cases out
of the latter, the dog had been imported to Finland
from a country that is not rabies-free.
Malaria, dengue fever
and other travel-related
infections
Malaria
Malaria was diagnosed in 48 patients in Finland in
2012. There were 36 cases of Plasmodium falciparum,
six cases of P. vivax and six cases of P. ovale. The majority of the infections were contracted in Africa (40
cases, or 83%), 28 of them in western Africa. Five
infections were acquired on the Indian subcontinent,
and three each in Southeast Asia and Oceania. Of the
patients, 17 (35%) were native Finns who had been
travelling in a malarious area for less than six months,
and two were Finns resident in a malarious area; 21
(43%) were immigrants from a malarious area who
had been visiting their home country, and four were
immigrants who had fallen ill immediately after arriving in Finland. Four patients were visitors to Finland. The countries where patients acquired malaria
and the risk groups remained approximately the same
as in previous years.
Dengue fever
Dengue fever cases have been on the increase in recent
years, with 35 to 50 cases per year. In 2011, laboratories reported 45 findings; the figure for 2012 was 90.
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43
Infectious Diseases in Finland 2012
Table 14. Malaria cases in Finland in 2012 by country
of acquisition.
Continent
Country
Asia
India
4
Pakistan
1
Thailand
2
Africa
Oceania
Cases
Total
7
Gambia
5
Ghana
6
Cameroon
1
Liberia
2
Nigeria
7
Ivory Coast
1
Senegal
2
Sierra Leone
4
Congo
2
Southern Sudan
2
Kenya
2
Malawi
1
Sudan
3
Uganda
2
Total
40
Papua New Guinea
1
Total
Total
1
48
Comprehensive data on the countries of acquisition
are not available. Seven cases where the infection was
contracted on a trip to Madeira were reported to the
National Institute for Health and Welfare.
Other travel-related infections
A significant percentage of the following infections
are travel-related: legionella, salmonella, campylobacter, shigella, EHEC, hepatitis A, hepatitis B, gonorrhoea, syphilis, HIV and AIDS, carbapenem-resistant gram-negative bacilli and MMR diseases; the data
on country of acquisition and means of transmission
are discussed separately for each of these in their respective sections.
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Infectious Diseases in Finland 2012
Blood and CFS findings in
children
Blood culture findings in children
The number of blood culture positive cases in children under 15 reported in 2012 was 424, slightly less
than in recent years (average between 2000 and 2011
was 619, variation 530–687).
Over half of the findings (229 out of 424) were in
babies under 12 months old. Among infants, Staphylococcus epidermidis and other coagulase-negative
staphylococci caused 33% 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 (16% 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, as before, were Staphylococcus aureus (14% of the findings), Escherichia coli
(11%), Enterococcus faecalis (5%) and Streptococcus
pneumoniae (3%).
GBS in newborns
Between 1995 and 2012, an average of 33 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 22 to 57 cases per year, and
the incidence was 0.4 to 1.0 per 1,000 live births.
There were 22 cases in 2012 (0.4 cases per 1,000 live
births). An average of 15 annual cases of late GBS
disease cases detected at the age of more than 7 days
have occurred during the 17 year surveillance period
(range 6–24; incidence 0.1–0.4 cases per 1,000 live
births). There were 15 cases in 2012 (0.3 cases per
1,000 live births).
In the age group 1 to 14 years, S. aureus was the most
common causes of blood culture positive infections
in 2012 (24%). The incidence of the previous leading
cause, S. pneumoniae, was less than half of what it had
been in previous years (18%). A pneumococcus vaccination for children was added to the national vaccination programme in 2010. Other common findings
in this age group were coagulase-negative staphylococci (14%), the Streptococcus viridans group (7%) and
E. coli (7%).
Cerebrospinal fluid 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 2012 was 25 (annual average from
2000 to 2011 was 37, variation 18–56), of which 14
were diagnosed in infants under 12 months old. The
most common findings in the age group of under 12
months were meningococcus, S. aureus and S. agalactiae (Table 17); in the age group 1 to 14, the most
common findings were meningococci and S. aureus.
In 2012, only one finding of pneumococcus in CSF
in a patient under the age of 15 was reported.
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45
Infectious Diseases in Finland 2012
Table 15. Blood culture findings in infants (under 12 months), 2001–2012 (no. of cases).
46
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Staphylococcus epidermidis
76
76
61
110
98
100
92
87
64
71
76
49
Streptococcus agalactiae
41
46
37
45
73
55
51
49
51
54
42
36
Staphylococcus aureus
17
24
21
32
32
37
25
23
22
24
21
31
Staphylococcus, other
coagulase-negative
23
35
20
36
31
41
39
33
43
32
33
26
Escherichia coli
39
40
39
37
41
44
42
38
38
45
48
25
Enterococcus faecalis
6
11
11
9
15
22
8
5
10
20
12
11
Streptococcus pneumoniae
19
17
25
28
26
27
21
26
25
20
11
8
Klebsiella species
8
7
8
9
9
8
6
8
9
3
7
6
Streptococcus pyogenes
2
1
1
3
0
0
3
2
4
2
0
6
Enterobacter species
6
6
6
5
3
13
8
6
3
3
10
5
Haemophilus influenzae
3
0
2
1
2
1
1
2
2
1
0
4
Streptococcus viridans
group
10
8
13
15
12
10
9
8
9
18
11
3
Clostridium, other or
unidentified
1
0
1
1
0
2
0
1
1
1
0
2
Neisseria meningitidis
3
2
2
5
3
2
3
3
5
4
1
2
Acinetobacter species
0
4
3
1
1
3
2
1
1
3
2
1
Bacillus
2
0
1
2
2
1
4
4
2
1
1
1
Citrobacter species
2
1
1
0
1
1
0
0
1
1
0
1
Enterococcus, other or
unidentified
0
0
0
1
0
0
0
0
2
0
0
1
Listeria monocytogenes
1
0
0
0
0
2
1
0
1
2
0
1
Streptococcus, other betahaemolytic
0
1
1
2
0
1
0
0
3
2
0
1
Bacteroides fragilis group
1
0
0
0
0
0
1
1
0
1
0
0
Clostridium perfringens
0
1
0
0
1
0
0
0
0
0
0
0
Enterococcus faecium
1
2
2
3
2
3
0
1
2
2
1
0
Haemophilus, other than
influenzae
0
0
1
0
1
1
0
1
0
0
1
0
Morganella morganii
0
0
0
0
0
0
0
0
0
0
0
0
Peptostreptococcus ja
Peptococcus
1
0
0
0
0
0
0
0
0
1
0
0
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National Institute for Health and Welfare
Infectious Diseases in Finland 2012
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Prevotella species
0
0
0
0
0
0
0
1
0
0
0
0
Propionibacterium species
0
1
0
0
0
0
1
0
0
0
1
0
Proteus mirabilis
0
0
0
1
0
1
1
0
0
0
0
0
Proteus vulgaris
0
0
0
0
0
0
0
0
0
0
0
0
Pseudomonas aeruginosa
2
1
1
4
0
0
0
2
0
2
1
0
Salmonella, other than Typhi
0
1
0
0
0
0
0
0
1
0
1
0
Serratia species
0
5
2
4
0
2
3
4
1
2
4
0
Stenotrophomonas
maltophilia
0
1
1
0
1
0
2
0
2
2
0
0
Streptococcus bovis group
0
1
1
1
1
0
0
0
2
0
0
0
Streptococcus milleri group
0
1
0
0
0
1
0
0
0
0
0
0
Veillonella species
0
0
0
0
0
1
0
0
0
0
0
0
Other bacteria
4
12
9
8
4
5
10
7
5
4
10
6
Bacteria, total
268
305
270
363
359
384
333
313
309
321
294
226
Other candida species
8
8
2
0
1
0
1
1
0
0
1
2
Candida albicans
3
10
2
3
4
4
2
3
1
2
1
1
Other fungi
0
0
0
0
0
0
1
0
0
0
0
0
Fungi, total
11
18
4
3
5
4
4
4
1
2
2
3
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47
Infectious Diseases in Finland 2012
Table 16. Blood culture findings in children (aged 1 to 14), 2000–2012 (no. of cases).
48
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Staphylococcus aureus
38
58
47
58
41
37
43
40
36
43
42
46
Streptococcus pneumoniae
76
92
94
88
101
99
115
87
92
95
74
35
Staphylococcus epidermidis
26
40
30
25
41
40
33
22
31
37
29
17
Escherichia coli
5
13
13
15
10
16
12
14
12
15
11
14
Streptococcus viridans
group
23
13
13
18
24
24
23
21
25
36
20
14
Staphylococcus, other
coagulase-negative
18
14
16
9
13
8
18
13
16
21
13
11
Streptococcus pyogenes
9
10
12
4
0
9
13
11
11
6
16
9
Klebsiella species
2
6
4
5
10
3
6
5
2
4
2
6
Bacillus
2
5
6
2
7
6
0
6
3
3
2
5
Enterococcus faecalis
2
4
2
2
4
2
6
6
4
6
3
5
Pseudomonas aeruginosa
7
4
6
3
6
3
2
1
3
7
4
3
Salmonella, other than Typhi
1
1
1
1
1
2
5
2
0
6
2
3
Clostridium, other or
unidentified
1
2
1
0
3
2
4
1
1
2
1
2
Neisseria meningitidis
9
8
6
2
7
5
3
4
0
6
2
2
Propionibacterium species
0
0
1
0
0
0
0
0
0
0
0
2
Acinetobacter species
5
8
2
1
4
1
2
2
4
1
0
1
Enterobacter species
0
1
6
3
3
1
2
4
3
2
3
1
Enterococcus faecium
2
4
1
2
2
3
4
2
7
7
0
1
Fusobacterium species
1
3
0
1
2
3
5
5
1
1
1
1
Haemophilus, other than
influenzae
0
0
0
0
0
0
0
0
0
0
0
1
Peptostreptococcus ja
Peptococcus
1
0
0
0
0
0
0
0
0
0
2
1
Stenotrophomonas
maltophilia
2
0
1
3
0
1
3
4
2
2
0
1
Streptococcus milleri group
1
1
0
0
3
2
0
2
2
2
1
1
Streptococcus, other betahaemolytic
1
0
3
2
2
4
1
0
2
2
1
1
Bacteroides fragilis group
1
1
0
2
3
0
0
0
1
0
2
0
Bacteroides, other than
fragilis group
0
0
0
0
0
0
0
0
0
0
0
0
Report 12/2013
National Institute for Health and Welfare
Infectious Diseases in Finland 2012
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Campylobacter species
1
0
0
0
0
0
0
0
0
0
0
0
Citrobacter species
1
1
0
0
1
0
2
2
1
1
0
0
Clostridium perfringens
0
0
1
0
0
1
2
0
1
1
0
0
Enterococcus, other or
unidentified
0
0
2
2
0
2
2
3
0
1
0
0
Haemophilus influenzae
2
1
5
0
1
1
2
3
3
2
5
0
Listeria monocytogenes
1
0
1
0
0
0
0
0
0
0
0
0
Mycobacterium, other or
unidentified
0
0
0
0
0
0
0
0
0
0
1
0
Prevotella species
0
0
0
1
0
0
0
0
0
0
0
0
Proteus mirabilis
0
0
0
1
0
0
1
0
0
0
0
0
Pseudomonas, other than
aeruginosa
3
1
1
0
1
0
1
0
3
0
0
0
Salmonella Typhi
0
1
1
1
2
0
2
0
0
0
2
0
Serratia species
0
1
0
0
1
2
1
0
0
1
0
0
Streptococcus agalactiae
0
0
2
1
0
0
2
1
0
0
0
0
Streptococcus bovis group
0
0
0
0
0
1
0
0
0
0
0
0
Veillonella species
0
0
0
0
0
1
0
0
0
1
0
0
Yersinia pseudotuberculosis
0
0
1
0
0
0
0
0
0
0
0
0
Other bacteria
8
16
11
18
22
14
15
10
10
24
10
11
Bacteria, total
249
309
290
270
315
293
330
271
276
335
249
194
Candida albicans
1
2
1
0
1
1
0
2
0
2
0
1
Other candida species
0
0
0
1
0
2
3
1
0
0
2
0
Other fungi
0
1
2
0
0
2
1
0
0
0
1
0
Fungi, total
1
3
3
1
1
5
4
3
0
2
3
1
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National Institute for Health and Welfare
49
Infectious Diseases in Finland 2012
Table 17. Cerebrospinal fluid culture findings in infants (under 12 months), 2001–2012 (no. of cases).
50
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Neisseria meningitidis
4
1
2
4
0
1
2
1
2
1
0
3
Staphylococcus aureus
0
0
3
2
1
0
1
2
2
1
0
3
Streptococcus agalactiae
2
5
1
10
7
7
6
3
6
8
2
3
Staphylococcus, other
coagulase-negative
0
4
1
2
1
0
0
4
1
0
0
2
Clostridium, other than
perfringens
0
0
0
0
0
0
0
0
0
0
0
1
Klebsiella species
0
0
0
0
0
0
0
0
1
0
0
1
Staphylococcus epidermidis
1
3
3
3
3
3
2
1
2
2
2
1
Streptococcus pneumoniae
0
3
6
8
3
1
4
3
2
3
2
1
Acinetobacter species
0
1
0
0
0
1
0
0
0
0
0
0
Bacillus
0
0
0
0
0
1
0
0
0
0
0
0
Bacteroides, other than
fragilis group
0
0
0
0
0
0
1
0
0
0
0
0
Citrobacter species
0
0
0
0
0
0
1
0
0
1
0
0
Enterobacter species
0
0
0
1
0
0
0
0
0
0
0
0
Enterococcus faecalis
0
0
1
1
0
2
1
0
0
0
0
0
Enterococcus faecium
0
0
0
0
0
1
0
0
0
0
0
0
Escherichia coli
3
1
1
2
0
2
1
1
1
2
1
0
Haemophilus influenzae
1
0
1
0
1
0
0
0
1
0
0
0
Mycobacterium, other than
avium
0
0
0
0
0
0
0
0
0
1
0
0
Propionibacterium species
0
0
1
1
0
0
0
0
0
0
0
0
Serratia species
0
0
0
1
0
0
0
0
0
0
0
0
Streptococcus pyogenes
0
0
0
0
0
0
0
0
1
0
0
0
Streptococcus viridans
group
0
0
1
0
0
0
0
0
2
0
1
0
Other bacteria
0
2
1
1
0
0
0
0
1
0
0
0
Bacteria, total
11
20
22
36
16
19
19
15
22
19
8
15
Candida albicans
0
0
0
0
0
0
0
0
1
0
0
0
Fungi, total
0
0
0
0
0
0
0
0
1
0
0
0
Report 12/2013
National Institute for Health and Welfare
Infectious Diseases in Finland 2012
Table 18. Cerebrospinal fluid culture findings in children (aged 1 to 14), 2002–2012 (no. of cases).
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Neisseria meningitidis
5
7
4
4
5
7
5
3
2
3
4
2
Staphylococcus aureus
0
1
2
2
0
0
2
3
3
2
2
2
Enterobacter species
0
0
0
1
0
0
0
0
1
0
0
1
Escherichia coli
0
0
0
0
0
1
0
0
0
0
0
1
Staphylococcus epidermidis
0
7
1
4
2
0
1
5
2
1
2
1
Streptococcus pyogenes
0
1
0
0
0
0
0
0
0
0
0
1
Acinetobacter species
0
1
0
1
1
0
0
0
0
0
0
0
Bacteroides fragilis group
0
0
0
0
0
1
0
0
0
0
0
0
Citrobacter species
0
1
0
0
0
0
0
0
0
0
0
0
Corynebacterium species
0
0
0
0
0
0
0
2
0
1
0
0
Enterococcus faecalis
0
0
0
1
1
0
0
0
0
1
0
0
Enterococcus faecium
0
1
0
1
0
0
0
0
0
0
0
0
Haemophilus influenzae
1
0
2
0
0
0
0
0
0
0
1
0
Mycobacterium, other than
avium
0
0
1
0
0
0
0
0
0
0
0
0
Peptostreptococcus ja
Peptococcus
0
0
0
0
0
1
0
0
0
0
0
0
Propionibacterium species
0
0
0
0
1
0
0
0
0
0
1
0
Staphylococcus, other
coagulase-negative
0
3
2
2
2
0
0
0
1
0
0
0
Stenotrophomonas
maltophilia
0
0
1
0
0
0
0
0
0
0
0
0
Streptococcus agalactiae
1
0
0
0
0
0
0
0
0
0
0
0
Streptococcus pneumoniae
0
2
10
2
1
5
5
2
4
2
3
0
Streptococcus viridans
group
0
0
1
1
0
2
0
0
0
0
0
0
Streptococcus, other betahaemolytic
0
1
0
0
0
0
0
0
1
0
0
0
Other bacteria
0
5
0
0
5
1
0
6
3
1
4
2
Bacteria, total
7
30
24
19
18
18
13
21
17
11
17
10
Candida albicans
0
0
0
1
0
0
0
0
0
0
0
1
Fungi, total
0
0
0
1
0
0
0
0
0
0
0
1
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National Institute for Health and Welfare
51
Infectious Diseases in Finland 2012
Blood and CFS findings in
adults
Blood culture findings in adults
The total number of blood culture findings in adults
in 2012 was 11,096 (2011: 11,153). The number of
blood culture findings in the age group of over 65
continued to grow, being 7,153 (2011: 7,002). Grampositive bacteria were more common in the workingage population (aged 15 to 64) and gram-negative
bacteria among those aged 65 or more. Anaerobic
bacteria constituted 5% and fungi 2% of all blood
culture positive findings among adults.
In the working-age population, the most common
bacterial finding was Escherichia coli, constituting
more than one fifth of all cases (Table 19). The next
most common findings were Staphylococcus aureus
(16%), Streptococcus pneumoniae (9%), coagulasenegative staphylococci (7%), 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 20). The next most
common findings were Staphylococcus aureus (11%),
coagulase-negative staphylococci (7%), Klebsiella species (7%) and Streptococcus pneumoniae (5%).
Cerebrospinal fluid findings in adults
The total number of cerebrospinal fluid findings in
adults in 2012 was 135 (2000–2011 average 143, variation 32–193). Patients over the age of 65 accounted for 22% of the cases (30 out of 135). Coagulasenegative staphylococcus was reported in 27% of the
cases in working-age patients (Table 22). The most
common pathogens were pneumococcus (17%), S.
aureus (14%) and meningococcus (6%). In patients
aged 65 years or older, coagulase-negative staphylococcus accounted for 33% of the findings (Table 23).
The most commonly reported pathogens were pneumococcus (13%), S. aureus (7%) and Listeria monocytogenes (10%).
Group A streptococcus
The number of cases of Group A streptococcus (Streptococcus pyogenes) reported to the NIDR increased on
the previous year, being 216 (2011: 170). In an epidemic found in the Satakunta Hospital District in
2012, two strains isolated from blood and six strains
isolated from screening samples were found to be of
emm type 1, which is associated with a severe form
of the disease. The prevalent emm types of Group
A streptococcus were the same as in previous years:
52
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National Institute for Health and Welfare
emm1, emm28 and emm89 (Table 21). What is noteworthy is that the increase of the percentage of cases
of emm89 on recent years. The percentage of cases
of emm12 has remained stable (7%), while the percentage of cases of the previously common emm84
continued to decline (less than 1%). Although new
emm types are emerging all the time, the four most
common emm types accounted for 77% of all cases
in 2012 (Table 21).
Infectious Diseases in Finland 2012
Table 19. Blood culture findings in patients aged 15 to 64, 2000–2012 (no. of cases).
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Escherichia coli
613
580
645
707
780
797
837
871
885
930
934
939
Staphylococcus aureus
451
462
448
488
459
565
549
529
540
585
645
620
Streptococcus pneumoniae
343
333
406
386
377
348
353
480
441
415
393
362
Klebsiella species
114
134
121
159
184
145
159
198
187
207
164
216
Staphylococcus epidermidis
300
305
286
294
286
281
265
279
313
264
223
180
Streptococcus pyogenes
60
93
78
100
76
105
134
157
118
113
102
126
Streptococcus, other betahaemolytic
66
78
79
101
96
127
117
113
113
131
139
119
Staphylococcus, other
coagulase-negative
106
138
114
126
113
120
141
151
137
139
143
104
Bacteroides fragilis group
64
61
59
67
83
85
82
109
68
110
109
103
Enterobacter species
92
53
60
62
49
77
70
69
82
99
86
96
Streptococcus agalactiae
76
78
68
64
99
76
83
96
95
110
75
89
Streptococcus viridans
group
118
105
126
141
141
130
118
140
144
150
139
88
Pseudomonas aeruginosa
72
73
85
58
88
62
72
74
78
91
92
79
Enterococcus faecalis
95
99
84
80
100
83
105
83
107
86
97
78
Streptococcus milleri group
46
48
48
48
54
62
64
72
57
68
86
78
Enterococcus faecium
61
53
51
45
66
69
81
91
89
91
108
64
Fusobacterium species
26
15
21
32
31
19
31
31
27
37
31
48
Salmonella, other than
Typhi
37
12
22
35
29
51
59
48
26
42
33
35
Bacillus
20
18
22
15
18
22
24
25
21
32
34
27
Citrobacter species
18
14
10
21
15
28
19
23
29
31
28
25
Haemophilus influenzae
14
9
14
11
13
9
26
18
19
18
22
25
Serratia species
10
12
14
10
16
18
19
24
27
20
32
25
Proteus mirabilis
20
15
11
15
12
18
14
14
18
26
17
23
Peptostreptococcus ja
Peptococcus
20
22
23
15
21
18
11
12
27
15
30
18
Clostridium, other or
unidentified
26
28
14
17
22
20
15
19
20
22
19
16
Enterococcus, other or
unidentified
9
14
10
10
11
6
4
7
13
13
12
16
Listeria monocytogenes
7
9
12
7
10
10
9
8
9
15
7
16
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National Institute for Health and Welfare
53
Infectious Diseases in Finland 2012
54
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Prevotella species
11
4
11
11
15
11
8
13
13
15
16
16
Acinetobacter species
9
13
10
16
16
10
21
13
18
14
21
14
Capnocytophaga
canimorsus
6
6
6
6
8
8
8
8
11
11
17
12
Neisseria meningitidis
19
20
18
18
16
20
21
9
13
14
17
12
Clostridium perfringens
8
6
9
6
16
11
12
10
16
16
8
11
Haemophilus, other than
influenzae
8
4
1
5
6
3
3
3
0
2
3
9
Pseudomonas, other than
aeruginosa
2
3
4
5
4
0
4
9
7
7
7
8
Morganella morganii
4
3
4
4
3
8
7
14
8
6
8
7
Propionibacterium species
19
8
11
6
9
7
5
3
9
6
9
7
Stenotrophomonas
maltophilia
15
14
6
12
12
7
5
15
12
12
9
7
Campylobacter species
14
7
10
13
5
3
8
7
11
10
4
6
Streptococcus bovis species
3
2
2
3
8
5
7
1
6
7
6
6
Veillonella species
4
2
3
1
6
3
5
3
7
5
13
6
Bacteroides, other than
fragilis group
6
5
0
5
2
4
3
5
10
1
7
3
Mycobacterium avium
3
0
1
0
2
2
2
1
2
2
2
3
Proteus vulgaris
3
0
3
4
3
7
3
2
3
2
2
3
Hafnia alvei
1
1
5
4
3
0
1
3
6
2
2
2
Mycobacterium, other or
unidentified
1
1
4
0
1
2
3
1
0
0
2
1
Salmonella Typhi
1
1
3
4
3
3
4
1
3
9
3
1
Yersinia pseudotuberculosis
2
2
1
1
0
0
0
1
0
0
0
1
Yersinia enterocolitica
1
0
0
0
1
0
0
0
1
1
0
0
Other bacteria
58
92
84
89
93
97
84
103
99
90
93
104
Bacteria, total
3082
3055
3127
3327
3481
3562
3675
3966
3945
4092
4049
3854
Candida albicans
44
29
43
45
42
54
55
55
55
57
74
56
Other candida species
27
23
35
24
22
22
25
42
28
37
30
31
Other fungi
0
2
1
2
1
2
2
4
5
2
5
2
Fungi, total
71
54
79
71
65
78
82
101
88
96
109
89
Report 12/2013
National Institute for Health and Welfare
Infectious Diseases in Finland 2012
Table 20. Blood culture findings in patients aged 65 or over, 2000–2012 (no. of cases).
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Escherichia coli
1179
1213
1314
1466
1624
1706
1760
1890
2056
2233
2482
2470
Staphylococcus aureus
407
452
467
486
484
602
570
675
692
731
783
799
Klebsiella species
241
230
253
341
339
326
338
420
462
468
473
536
Streptococcus pneumoniae
216
200
241
239
229
270
294
326
294
303
296
342
Staphylococcus
epidermidis
253
228
231
254
284
265
275
299
270
325
316
299
Streptococcus, other betahaemolytic
105
100
123
135
140
174
171
177
222
258
267
294
Pseudomonas aeruginosa
132
148
148
139
151
154
188
191
184
218
196
249
Enterococcus faecalis
142
149
146
192
183
202
220
217
222
229
275
216
Bacteroides fragilis group
104
96
118
120
135
119
135
146
164
178
203
181
Enterobacter species
97
87
97
92
115
95
105
131
128
156
157
172
Staphylococcus, other
coagulase-negative
108
134
112
114
116
129
139
165
155
143
156
170
Enterococcus faecium
61
48
76
97
74
108
132
126
175
180
198
135
Proteus mirabilis
51
57
62
80
57
68
93
99
102
106
98
129
Streptococcus agalactiae
61
49
62
76
84
81
77
94
104
126
113
117
Citrobacter species
39
40
44
43
42
42
35
65
59
76
59
95
Streptococcus viridans
group
93
83
103
103
106
110
115
140
135
132
138
89
Streptococcus pyogenes
28
46
28
33
34
48
58
50
63
50
50
75
Serratia species
30
15
28
18
33
27
33
50
37
59
56
65
Streptococcus milleri
group
30
28
43
45
50
67
54
53
62
59
58
65
Clostridium perfringens
31
26
27
32
29
36
39
34
49
40
51
56
Haemophilus influenzae
27
15
13
13
28
21
25
21
22
19
37
51
Listeria monocytogenes
15
11
19
18
20
26
26
26
20
44
31
36
Clostridium, other or
unidentified
25
23
18
25
21
22
31
18
27
35
24
26
Enterococcus, other or
unidentified
21
18
19
16
17
19
15
24
20
24
33
26
Peptostreptococcus ja
Peptococcus
9
14
20
13
17
22
25
14
29
36
26
24
Acinetobacter species
18
17
8
13
10
18
11
12
16
16
17
19
Fusobacterium species
6
16
7
13
10
9
15
10
8
17
14
19
Report 12/2013
National Institute for Health and Welfare
55
Infectious Diseases in Finland 2012
56
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Streptococcus bovis group
10
7
9
20
12
17
17
15
25
12
12
17
Bacteroides, other than
fragilis group
5
3
5
8
4
3
5
8
13
8
8
16
Morganella morganii
9
13
10
14
21
14
26
11
18
29
30
16
Salmonella, other than
Typhi
4
7
5
6
15
11
8
19
6
8
7
13
Proteus vulgaris
8
7
8
7
9
9
9
4
4
8
8
12
Pseudomonas, other than
aeruginosa
3
6
6
3
7
9
11
10
11
10
8
11
Hafnia alvei
7
1
1
4
4
3
6
8
7
7
1
8
Stenotrophomonas
maltophilia
8
3
6
10
6
10
8
3
6
7
4
8
Bacillus
17
11
10
10
10
17
9
11
12
7
14
7
Capnocytophaga
canimorsus
1
1
1
1
1
4
2
3
2
2
6
7
Prevotella species
8
11
4
11
10
10
8
11
15
13
14
7
Propionibacterium species
12
15
4
8
13
9
4
5
9
10
13
6
Neisseria meningitidis
4
4
4
3
2
5
2
6
6
6
6
5
Veillonella species
0
0
1
1
7
2
6
9
5
4
6
5
Campylobacter species
3
3
1
5
3
5
3
5
6
3
1
4
Haemophilus, other than
influenzae
0
2
1
3
2
2
1
1
1
1
0
3
Yersinia enterocolitica
1
1
3
1
1
1
1
0
1
1
0
3
Mycobacterium, other or
unidentified
2
0
2
3
0
5
1
3
0
5
1
1
Yersinia
pseudotuberculosis
2
1
1
2
2
1
1
0
3
1
0
1
Mycobacterium avium
0
1
0
0
1
0
0
1
0
0
0
0
Salmonella Typhi
0
0
1
0
1
0
0
0
0
0
0
0
Other bacteria
59
68
87
96
96
96
82
124
123
121
143
139
Bacteria, total
3692
3708
3997
4432
4659
4999
5189
5730
6050
6524
6889
7044
Candida albicans
48
39
63
51
39
54
56
66
49
93
65
70
Other candida species
22
31
46
27
25
22
27
25
42
33
44
39
Other fungi
1
0
3
0
3
0
0
2
0
0
4
0
Fungi, total
71
70
112
78
67
76
83
93
91
126
113
109
Report 12/2013
National Institute for Health and Welfare
Infectious Diseases in Finland 2012
Table 21. Group A Streptococcus blood findings by emm-type, 2006–2012 (no. of cases and %).
Cases
notified to
NIDR
Stains
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 %)
2011
163
25 (15 %)
37 (23 %)
4 (2 %)
30 (18 %)
66 (40 %)
1 (<1 %)
2012
210
23 (11 %)
66 (31 %)
1 (<1 %)
58 (28 %)
57 (27 %)
5 (2 %)
Report 12/2013
National Institute for Health and Welfare
57
Infectious Diseases in Finland 2012
Table 22. Cerebrospinal fluid culture findings in patients aged 15 to 64, 2001–2012 (no. of cases).
58
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Staphylococcus
epidermidis
1
27
21
24
34
32
17
27
18
11
10
21
Streptococcus
pneumoniae
4
19
26
21
16
17
14
26
19
15
12
18
Staphylococcus aureus
0
6
10
17
10
9
16
13
13
12
20
15
Staphylococcus, other
coagulase-negative
0
12
6
16
14
12
7
14
10
8
6
7
Clostridium, other than
perfringens
0
0
0
0
0
0
0
0
0
0
0
6
Neisseria meningitidis
12
19
15
11
15
20
16
4
9
6
7
6
Propionibacterium species
0
6
6
11
5
5
5
4
4
7
4
5
Enterobacter species
0
1
0
3
5
2
2
9
3
1
2
4
Pseudomonas aeruginosa
0
5
4
2
4
6
3
4
5
3
1
4
Enterococcus faecalis
3
2
3
5
3
4
5
4
3
4
3
3
Acinetobacter species
0
2
1
1
3
3
5
2
3
0
2
2
Bacillus
0
5
0
0
3
6
4
3
0
0
0
2
Enterococcus faecium
0
1
0
2
1
0
1
0
1
0
2
2
Escherichia coli
0
3
0
0
7
4
3
3
4
1
1
2
Mycobacterium, other
than avium
0
2
1
0
0
0
1
2
0
0
0
2
Capnocytophaga
canimorsus
0
0
0
0
0
0
0
0
1
0
0
1
Citrobacter species
0
0
1
1
2
0
1
0
0
1
0
1
Corynebacterium species
0
0
1
1
2
1
1
0
1
0
0
1
Haemophilus influenzae
4
2
0
1
0
0
0
3
1
0
2
1
Streptococcus agalactiae
0
1
0
2
0
1
5
2
0
2
0
1
Streptococcus viridans
group
0
6
2
1
4
7
2
1
2
2
4
1
Campylobacter species
0
0
0
0
1
0
0
0
0
0
0
0
Enterococcus, other or
unidentified
1
1
0
0
0
1
1
1
0
0
1
0
Haemophilus, other than
influenzae
0
0
0
0
0
0
1
0
0
0
2
0
Klebsiella species
0
0
0
0
0
0
0
4
2
1
2
0
Listeria monocytogenes
1
0
2
1
0
2
1
1
2
1
1
0
Report 12/2013
National Institute for Health and Welfare
Infectious Diseases in Finland 2012
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Morganella morganii
0
1
0
0
0
0
0
0
0
0
0
0
Peptostreptococcus ja
Peptococcus
0
0
2
0
0
0
0
0
1
0
0
0
Prevotella species
0
1
0
0
0
0
0
0
0
0
0
0
Proteus mirabilis
0
0
0
0
0
0
0
0
0
0
1
0
Pseudomonas, other than
aeruginosa
0
0
1
0
0
1
1
1
1
0
1
0
Salmonella, other than
Typhi
1
0
1
0
0
0
0
2
0
0
1
0
Serratia group
0
0
2
1
1
0
3
0
0
0
1
0
Stenotrophomonas
maltophilia
0
0
0
1
0
0
1
0
0
0
1
0
Streptococcus bovis group
0
0
0
0
0
0
0
0
0
1
0
0
Streptococcus milleri
group
0
0
0
0
0
0
0
1
0
0
0
0
Streptococcus pyogenes
0
1
1
0
0
1
0
2
2
1
1
0
Streptococcus, other betahaemolytic
0
2
0
1
1
0
0
1
2
1
2
0
Other bacteria
0
6
3
3
5
10
7
5
7
2
6
3
Bacteria, total
27
131
109
126
136
144
123
139
114
80
96
108
Other candida species
0
1
0
3
1
3
4
1
0
1
0
2
Candida albicans
0
1
1
2
1
0
1
0
0
0
0
1
Other fungi
0
0
0
0
0
0
1
0
0
0
0
0
Fungi, total
0
2
1
5
2
3
6
1
0
1
0
3
Report 12/2013
National Institute for Health and Welfare
59
Infectious Diseases in Finland 2012
Table 23. Cerebrospinal fluid culture findings in patients aged 65 or over, 2001–2012 (no. of cases).
60
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Staphylococcus
epidermidis
1
7
5
6
10
9
12
10
6
2
4
7
Clostridium, other than
perfringens
0
0
0
0
0
0
0
0
0
0
0
6
Streptococcus pneumoniae
0
4
5
4
8
10
4
7
10
6
7
4
Listeria monocytogenes
1
2
4
2
4
3
2
2
2
6
4
3
Staphylococcus, other
coagulase-negative
0
5
4
5
5
3
2
3
3
3
1
3
Propionibacterium species
1
4
0
1
0
2
0
2
2
1
1
2
Staphylococcus aureus
0
2
7
7
5
3
2
3
6
5
5
2
Bacillus
0
3
0
0
0
0
0
1
0
0
2
1
Enterobacter species
0
2
0
1
0
0
1
0
0
1
1
1
Enterococcus faecalis
1
2
3
0
2
2
3
0
1
0
0
1
Enterococcus faecium
0
0
1
0
0
0
0
0
1
0
0
1
Escherichia coli
1
1
2
2
1
1
0
1
1
1
2
1
Neisseria meningitidis
1
0
1
1
2
1
0
1
0
2
0
1
Peptostreptococcus ja
Peptococcus
0
0
1
0
0
0
0
0
0
0
0
1
Pseudomonas aeruginosa
0
0
0
1
0
1
0
2
0
0
0
1
Acinetobacter species
0
2
1
0
0
1
1
0
0
0
0
0
Bacteroides fragilis group
0
0
0
0
0
0
0
0
1
0
0
0
Citrobacter species
0
0
0
0
0
0
0
0
0
0
1
0
Corynebacterium species
0
0
1
0
0
0
0
0
0
1
0
0
Enterococcus, other or
unidentified
0
1
0
0
0
0
0
0
0
1
0
0
Haemophilus influenzae
0
0
0
0
1
2
2
1
1
0
1
0
Klebsiella species
0
0
0
0
0
0
0
1
1
0
0
0
Mycobacterium avium
0
0
0
0
1
0
0
0
0
0
0
0
Mycobacterium, other
than avium
1
1
4
1
3
0
0
1
1
0
1
0
Proteus mirabilis
0
0
0
0
0
0
0
1
1
0
0
0
Proteus vulgaris
0
0
0
0
1
0
0
0
0
0
0
0
Pseudomonas, other than
aeruginosa
0
0
0
1
0
0
0
0
0
0
0
0
Report 12/2013
National Institute for Health and Welfare
Infectious Diseases in Finland 2012
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Serratia species
0
0
0
1
0
0
0
0
0
0
0
0
Stenotrophomonas
maltophilia
0
0
0
1
0
0
0
0
0
0
0
0
Streptococcus agalactiae
2
0
1
0
0
0
0
0
1
1
0
0
Streptococcus bovis group
0
0
0
0
0
0
0
0
1
0
0
0
Streptococcus milleri
group
0
0
0
0
0
0
0
0
1
0
0
0
Streptococcus pyogenes
0
2
0
0
0
0
0
0
0
0
0
0
Streptococcus viridans
group
0
1
0
1
0
1
1
0
3
1
0
0
Streptococcus, other betahaemolytic
0
0
2
0
1
0
0
0
1
0
0
0
Other bacteria
0
3
2
1
2
3
2
1
1
5
3
0
Bacteria, total
9
42
44
36
46
42
32
37
45
36
33
35
Candida albicans
0
0
0
0
1
0
0
1
0
0
0
1
Other candida species
0
2
0
1
0
2
0
0
2
0
2
0
Fungi, total
0
2
0
1
1
2
0
1
2
0
2
1
Report 12/2013
National Institute for Health and Welfare
61
Infectious Diseases in Finland 2012
Table 24. Blood culture findings in all age groups, 2001–2012 (no. of cases).
62
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Escherichia coli
1836
1846
2011
2225
2455
2563
2651
2813
2991
3223
3475
3448
Staphylococcus aureus
913
996
983
1064
1016
1241
1187
1267
1290
1383
1491
1496
Klebsiella species
365
377
386
514
542
482
509
631
660
682
646
764
Streptococcus pneumoniae
654
642
766
741
733
744
783
919
852
833
774
747
Staphylococcus epidermidis
655
649
608
683
709
686
665
687
678
697
644
545
Streptococcus, other betahaemolytic
172
179
206
240
238
306
289
290
340
393
407
415
Pseudomonas aeruginosa
213
226
240
204
245
219
262
268
265
318
293
331
Staphylococcus, other
coagulase-negative
255
321
262
285
273
298
337
362
351
335
345
311
Enterococcus faecalis
245
263
243
283
302
309
339
311
343
341
387
310
Bacteroides fragilis group
170
158
177
189
221
204
218
256
233
289
314
284
Enterobacter species
195
147
169
162
170
186
185
210
216
260
256
274
Streptococcus agalactiae
178
173
169
186
256
212
213
240
250
290
230
242
Streptococcus pyogenes
99
150
119
140
110
162
208
220
196
171
168
216
Enterococcus faecium
125
107
130
147
144
183
217
220
273
280
307
200
Streptococcus viridans
group
244
209
255
277
283
274
265
309
313
336
308
194
Proteus mirabilis
71
72
73
97
69
87
109
113
120
132
115
152
Streptococcus milleri group
77
78
91
93
107
132
118
127
121
129
145
144
Citrobacter species
60
56
55
64
59
71
56
90
90
109
87
121
Serratia group
40
33
44
32
50
49
56
78
65
82
92
90
Haemophilus influenzae
46
25
34
25
44
32
54
44
46
40
64
80
Fusobacterium species
33
34
28
46
43
31
51
46
36
55
46
68
Clostridium perfringens
39
33
37
38
46
48
53
44
66
57
59
67
Listeria monocytogenes
24
20
32
25
30
38
36
34
30
61
38
53
Salmonella, other than
Typhi
42
21
28
42
45
64
72
69
33
56
43
51
Clostridium, other or
unidentified
53
53
34
43
46
46
50
39
49
60
44
46
Enterococcus, other or
unidentified
30
32
31
29
28
27
21
34
35
38
45
43
Peptostreptococcus ja
Peptococcus
31
36
43
28
38
40
36
26
56
52
58
43
Report 12/2013
National Institute for Health and Welfare
Infectious Diseases in Finland 2012
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Bacillus
41
34
39
29
37
46
37
46
38
43
51
40
Acinetobacter species
32
42
23
31
31
32
36
28
39
34
40
35
Morganella morganii
13
16
14
18
24
22
33
25
26
35
38
23
Prevotella species
19
15
15
23
25
21
16
25
28
28
30
23
Streptococcus bovis group
13
10
12
24
21
23
24
16
33
19
18
23
Neisseria meningitidis
35
34
30
28
28
32
29
22
24
30
26
21
Bacteroides, other than
fragilis group
11
8
5
13
6
7
8
13
23
9
15
19
Capnocytophaga
canimorsus
7
7
7
7
9
12
10
11
13
13
23
19
Pseudomonas, other than
aeruginosa
8
10
11
8
12
9
16
19
21
17
15
19
Stenotrophomonas
maltophilia
25
18
14
25
19
18
18
22
22
23
13
16
Propionibacterium species
31
24
16
14
22
16
10
8
18
16
23
15
Proteus vulgaris
11
7
11
11
12
16
12
6
7
10
10
15
Haemophilus, other than
influenzae
8
6
3
8
9
6
4
5
1
3
4
13
Veillonella species
4
2
4
2
13
7
11
12
12
10
19
11
Campylobacter species
18
10
11
18
8
8
11
12
17
13
5
10
Hafnia alvei
8
2
6
8
7
3
7
11
13
9
3
10
Mycobacterium avium
3
1
1
0
3
2
2
2
2
2
2
3
Yersinia enterocolitica
2
1
3
1
2
1
1
0
2
2
0
3
Mycobacterium, other or
unidentified
3
1
6
3
1
7
4
4
0
5
4
2
Yersinia pseudotuberculosis
4
3
3
3
2
1
1
1
3
1
0
2
Salmonella Typhi
1
2
5
5
6
3
6
1
3
9
5
1
Other bacteria
129
188
191
211
215
212
191
244
237
239
256
260
Bacteria, total
7291
7377
7684
8392
8814
9238
9527
10280
10580
11272
11481
11318
Candida albicans
96
80
109
99
86
113
113
126
105
154
140
128
Other candida species
57
62
83
52
48
46
56
69
70
70
77
72
Other fungi
1
3
6
2
4
4
4
6
5
2
10
2
Fungi, total
154
145
198
153
138
163
173
201
180
226
227
202
Report 12/2013
National Institute for Health and Welfare
63
Infectious Diseases in Finland 2012
Table 25. Cerebrospinal fluid culture findings in all age groups, 2002–2012 (no. of cases).
64
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Staphylococcus
epidermidis
3
44
30
37
49
44
32
43
28
16
18
30
Streptococcus pneumoniae
4
28
47
35
28
33
27
38
35
26
24
23
Staphylococcus aureus
0
9
22
28
16
12
21
21
24
20
27
22
Clostridium, other than
perfringens
0
0
0
0
0
0
0
0
0
0
0
13
Neisseria meningitidis
22
27
22
20
22
29
23
9
13
12
11
12
Staphylococcus, other
coagulase-negative
0
24
13
25
22
15
9
21
15
11
7
12
Propionibacterium species
1
10
7
13
6
7
5
6
6
8
6
7
Enterobacter species
0
3
0
6
5
2
3
9
4
2
3
6
Pseudomonas aeruginosa
0
5
4
3
4
7
3
6
5
3
1
5
Enterococcus faecalis
4
4
7
7
6
8
9
4
4
5
3
4
Escherichia coli
4
5
3
4
8
8
4
5
6
4
4
4
Streptococcus agalactiae
5
6
2
12
7
8
11
5
7
11
2
4
Bacillus
0
8
0
0
3
7
4
4
0
0
2
3
Enterococcus faecium
0
2
1
3
1
1
1
0
2
0
2
3
Listeria monocytogenes
2
2
6
3
4
5
3
3
4
7
5
3
Acinetobacter species
0
6
2
2
4
5
6
2
3
0
2
2
Mycobacterium, other
than avium
1
3
6
1
3
0
1
3
1
1
1
2
Capnocytophaga
canimorsus
0
0
0
0
0
0
0
0
1
0
0
1
Citrobacter species
0
1
1
1
2
0
2
0
0
2
1
1
Corynebacterium species
0
0
2
1
2
1
1
2
1
2
0
1
Haemophilus influenzae
6
2
3
1
2
2
2
4
3
0
4
1
Klebsiella species
0
0
0
0
0
0
0
5
4
1
2
1
Peptostreptococcus ja
Peptococcus
0
0
3
0
0
1
0
0
1
0
0
1
Streptococcus pyogenes
0
4
1
0
0
1
0
2
3
1
1
1
Streptococcus viridans
group
0
7
4
3
4
10
3
1
7
3
5
1
Bacteroides fragilis group
0
0
0
0
0
1
0
0
1
0
0
0
Bacteroides, other than
fragilis species
0
0
0
0
0
0
1
0
0
0
0
0
Report 12/2013
National Institute for Health and Welfare
Infectious Diseases in Finland 2012
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Campylobacter species
0
0
0
0
1
0
0
0
0
0
0
0
Enterococcus, other or
unidentified
1
2
0
0
0
1
1
1
0
1
1
0
Haemophilus,other than
influenzae
0
0
0
0
0
0
1
0
0
0
2
0
Morganella morganii
0
1
0
0
0
0
0
0
0
0
0
0
Mycobacterium avium
0
0
0
0
1
0
0
0
0
0
0
0
Prevotella species
0
1
0
0
0
0
0
0
0
0
0
0
Proteus mirabilis
0
0
0
0
0
0
0
1
1
0
1
0
Proteus vulgaris
0
0
0
0
1
0
0
0
0
0
0
0
Pseudomonas, other than
aeruginosa
0
0
1
1
0
1
1
1
1
0
1
0
Salmonella, other than
Typhi
1
0
1
0
0
0
0
2
0
0
1
0
Serratia species
0
0
2
3
1
0
3
0
0
0
1
0
Stenotrophomonas
maltophilia
0
0
1
2
0
0
1
0
0
0
1
0
Streptococcus bovis group
0
0
0
0
0
0
0
0
1
1
0
0
Streptococcus milleri
group
0
0
0
0
0
0
0
1
1
0
0
0
Streptococcus, muut
betahemolyyttiset
0
3
2
1
2
0
0
1
4
1
2
0
Other bacteria
0
16
6
5
12
14
9
12
12
8
13
5
Bacteria, total
54
223
199
217
216
223
187
212
198
146
154
168
Candida albicans
0
1
1
3
2
0
1
1
1
0
0
3
Other candida species
0
3
0
4
1
5
4
1
2
1
2
2
Other fungi
0
0
0
0
0
0
1
0
0
0
0
0
Fungi, total
0
4
1
7
3
5
6
2
3
1
2
5
Report 12/2013
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65
Infectious Diseases in Finland 2012
Authors
Respiratory infections
Influenza A and B
Niina Ikonen, Outi Lyytikäinen, Ilkka Julkunen,
Hanna Nohynek (THL)
RSV
Niina Ikonen, Outi Lyytikäinen (THL)
Legionella
Marjo Vuorela, Jaana Kusnetsov, Silja Mentula,
Sari Jaakola, Outi Lyytikäinen (THL)
Whooping cough
Marjo Vuorela, Qiushui He, Hanna Nohynek
(THL)
Adenovirus
Niina Ikonen, Outi Lyytikäinen (THL)
Parainfluenza
Niina Ikonen, Outi Lyytikäinen (THL)
Mycoplasma pneumoniae
Mirja Puolakkainen (University of Helsinki)
Chlamydia pneumoniae
Mirja Puolakkainen (University of Helsinki)
Gastrointestinal infections
Salmonella
Ruska Rimhanen-Finne, Saara Salmenlinna, Anja
Siitonen (THL)
Campylobacter
Markku Kuusi, Anja Siitonen (THL)
Yersinia
Elisa Huovinen, Anja Siitonen (THL)
Clostridium difficile
Outi Lyytikäinen, Silja Mentula (THL)
Food-borne epidemics
Ruska Rimhanen-Finne, Anja Siitonen, Saara
Salmenlinna (THL)
Hepatitides
Hepatitis A
Markku Kuusi, Irja Davidkin, Tuija Leino (THL)
Hepatitis B
Henrikki Brummer-Korvenkontio, Kirsi Liitsola,
Tuija Leino (THL)
Hepatitis C
Henrikki Brummer-Korvenkontio, Kirsi Liitsola
(THL)
Sexually transmitted diseases
Chlamydia
Eija Hiltunen-Back (HUS)
Gonorrhoea
Eija Hiltunen-Back (HUS)
Syphilis
Eija Hiltunen-Back (HUS)
HIV and AIDS
Henrikki Brummer-Korvenkontio, Kirsi Liitsola
(THL)
Antimicrobial resistance
MRSA
Outi Lyytikäinen, Laura Lindholm, Jaana Vuopio
(THL)
Shigella
Markku Kuusi, Anja Siitonen (THL)
VRE
Outi Lyytikäinen, Laura Lindholm, Jaana Vuopio
(THL)
EHEC
Ruska Rimhanen-Finne, Aino Kyyhkynen, Saara
Salmenlinna, Anja Siitonen (THL)
ESBL
Outi Lyytikäinen, Jari Jalava (THL),
Juha Kirveskari (Huslab)
Norovirus
Merja Roivainen, Markku Kuusi (THL),
Leena Maunula (University of Helsinki)
Invasive pneumococcal disease
Outi Lyytikäinen, Jari Jalava, Maija Toropainen,
Lotta Siira, Arto Palmu, Pekka Nuorti (THL)
Rotavirus
Marjo Vuorela, Merja Roivainen, Tuija Leino (THL),
Leena Maunula (University of Helsinki)
Enterovirus
Katri Jalava, Merja Roivainen, Outi Lyytikäinen
(THL)
66
Listeria
Ruska Rimhanen-Finne, Saara Salmenlinna (THL)
Report 12/2013
National Institute for Health and Welfare
Tuberculosis
Tuberculosis
Petri Ruutu, Hanna Soini (THL),
Tuula Vasankari (Filha)
Infectious Diseases in Finland 2012
Other infections
Haemophilus
Marjo Vuorela, Maija Toropainen, Tuija Leino
(THL)
Meningococcus
Marjo Vuorela, Maija Toropainen, Anni Vainio,
Hanna Nohynek (THL)
MMR diseases (measles, mumps, rubella)
Marjo Vuorela, Irja Davidkin, Tuija Leino (THL)
Varicella virus
Marjo Vuorela, Tuija Leino (THL)
Puumala virus
Katri Jalava (THL),
Olli Vapalahti (University of Helsinki)
Tick-borne encephalitis (TBE)
Marjo Vuorela, Tuija Leino, Pirjo Turtiainen (THL),
Olli Vapalahti (University of Helsinki)
Tularemia
Heidi Rossow (THL)
Pogosta disease
Katri Jalava (THL),
Satu Kurkela (University of Helsinki)
Borrelia
Marjo Vuorela (THL)
Rabies
Marjo Vuorela, Ruska Rimhanen-Finne (THL)
Malaria
Heli Siikamäki (HUS)
Dengue fever and other travel-related
infections
Eeva Pekkanen (THL)
Blood and cerebrospinal fluid findings in
children
Marjo Vuorela, Outi Lyytikäinen, Arto Palmu
(THL)
Blood and cerebrospinal fluid findings in
adults
Marjo Vuorela, Outi Lyytikäinen (THL)
Group A streptococcus
Kati Räisänen, Jaana Vuopio (THL)
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