A controlled survey of less typical long-term consequences after an extensive waterborne epidemic.

BACKGROUND: Extensive backflow of treated wastewater caused household water contamination in a Finnish town in 2007. The drinking water of 9 500 residents became heavily polluted with faecal microbes, resulting in a large gastroenteritis epidemic. Cases of reactive arthritis, milder joint symptoms and prolonged gastrointestinal symptoms were observed after the outbreak. A follow-up survey was performed to study less familiar long-term health consequences within a year from the outbreak. METHODS: The contaminated group comprised a sample of residents of the area with polluted water supply (N = 323) and the control group a sample of residents in a nearby municipality (N = 186). The presence of 20 general symptoms or complaints was inquired by a mail survey. Quarterly prevalence of each symptom or complaint was measured. Twelve of these proceeded to further analysis. RESULTS: The response rate was 53% (323/615) in the contaminated group and 54% (186/343) in the control group. Rash, eye irritation, heartburn and weight loss were more prevalent in the contaminated group during the first year quarter. In the last year quarter, only eye irritation was significantly more common in the contaminated group. CONCLUSION: The excess prevalence of four complaints at the first year quarter can be explained by acute gastroenteritis or intensive water chlorination. The excess prevalence of eye irritation at the fourth year quarter cannot be explained by chlorination anymore but might be a sign of co-existing reactive joint disease. In general, long-term consequences of the outbreak can be considered minor in terms of the surveyed symptoms or complaints.

[Effect of MRSA on treatment and care in Finland - applications for compensation and complaints in 1993 to 2012]. / MRSA:n vaikutus hoitoon ja hoivaan Suomessa - korvausanomukset ja kantelut 1993-2012.

Events involving applications for compensation or filing a complaint in a MRSA case in Finland by patients or family members were studied for over a twenty-year period. The number of cases found was 305. Of the applications, only 7% resulted in compensation, and none of the complaints led to a change in decision. The discontentment was more commonly associated with the possible MRSA-induced impairment of the given treatment or limitations in freedom than with the fear of the direct health effects of the infection. In order to avoid problems, essential aspects include an intimate knowledge of guidelines among those working in the treatment and care sector, and proper informing of the patients about the effects of MRA on life.

The duration of gastrointestinal and joint symptoms after a large waterborne outbreak of gastroenteritis in Finland in 2007--a questionnaire-based 15-month follow-up study.

An extensive drinking water-associated gastroenteritis outbreak took place in the town of Nokia in Southern Finland in 2007. 53% of the exposed came down with gastroenteritis and 7% had arthritis-like symptoms (joint swelling, redness, warmth or pain in movement) according to a population-based questionnaire study at 8 weeks after the incident. Campylobacter and norovirus were the main pathogens. A follow-up questionnaire study was carried out 15 months after the outbreak to evaluate the duration of gastrointestinal and joint symptoms. 323 residents of the original contaminated area were included. The response rate was 53%. Participants were inquired about having gastroenteritis during the outbreak and the duration of symptoms. Of those with gastroenteritis, 43% reported loose stools and abdominal pain or distension after the acute disease. The prevalence of symptoms declined promptly during the first 3 months but at 15 months, 11% reported continuing symptoms. 32% of the respondents with gastroenteritis reported subsequent arthritis-like symptoms. The disappearance of arthritis-like symptoms was more gradual and they levelled off only after 5 months. 19% showed symptoms at 15 months. Prolonged gastrointestinal symptoms correlated to prolonged arthritis-like symptoms. High proportion of respondents continued to have arthritis-like symptoms at 15 months after the epidemic. The gastrointestinal symptoms, instead, had declined to a low level.

Excess healthcare costs of a large waterborne outbreak in Finland.

BACKGROUND: The economic effects of waterborne outbreaks have rarely been reported. A large waterborne outbreak occurred in the town of Nokia in Finland in 2007 with half of the population in the contaminated area suffering from gastroenteritis. We studied the healthcare costs of this outbreak. METHODS: Healthcare costs were studied using register data from the Nokia Health Care Centre, data collected in the regional university hospital, and data from laboratory register on stool samples. RESULTS: Total excess healthcare costs were EUR 354,496, which is approximately EUR 10 per resident of Nokia. There were 2052 excess visits because of gastroenteritis in Nokia Health Care Centre, 403 excess episodes in the university hospital, and altogether over 2000 excess stool samples due to the outbreak. Care in the Nokia Health Care Centre accounted for 44% and care in the university hospital for 42% of the excess healthcare costs while stool samples accounted for only 10%. CONCLUSIONS: Despite the high morbidity, the total cost was low because most patients had a relatively mild illness. The situation would have been worse if the microbes involved had been more hazardous or if the financial situation of the community had been worse. Prevention of waterborne outbreaks is important, as there is a risk of severe short- and long-term health effects and substantial health-economic costs.

Methicillin-resistant Staphylococcus aureus epidemic restricted to one health district in Finland: a population-based descriptive study in Pirkanmaa, Finland, years 2001-2011.

BACKGROUND: The incidence of methicillin-resistant Staphylococcus aureus (MRSA) has been low in the Scandinavian countries, including Finland. METHODS: We report a population-based, prospective survey of an exceptionally large ongoing MRSA epidemic in a Finnish health district (HD), Pirkanmaa HD, during 2001-2011 caused by 1 strain, spa t067 (FIN-16). RESULTS: The first FIN-16 case in the HD was identified in 2000. Ten years later, 2447 carriers had been found in 95 different institutions. MRSA in carriers was mostly health care-associated (98%). The epidemic emerged in long-term care facilities and gradually spread to acute hospitals. The majority of carriers were elderly people (median age 78 y). Fifty-two percent of new carriers had an infection with MRSA at the time of detection. CONCLUSIONS: The incidence of MRSA in Pirkanmaa HD is substantially higher than the incidence for all of Finland. Temporary projects to control MRSA have not proved sufficient to contain this large epidemic.

[Rationale for antimicrobial prophylaxis in surgery and its implementation in Finnish patient care]. / Kirurgisen mikrobilääkeprofylaksin perusteet ja toteutuminen suomalaisessa sairaanhoidossa.

Country-specific differences in bacterial antibiotic resistances cause variability in recommendations given in different countries. Mutually approved national expert and hospital-specific practices are therefore beneficial. Selection of the best prophylactic antimicrobial drug and correct timing of drug dosing are of high significance. In the light of our questionnaire survey prophylactic practices are relatively consistent in Finland. Hospitals have operation-specific recommendations on prophylaxis, but adherence to them is scarcely monitored. In fact, hospitals should invest in such monitoring systems.

Joint symptoms after a large waterborne gastroenteritis outbreak--a controlled, population-based questionnaire study.

OBJECTIVES: Waterborne outbreaks offer an opportunity to study joint symptoms after a simultaneous exposure. In November 2007, a gastroenteritis outbreak due to faecal contamination of tap water took place in a Finnish town. The purpose of this study was to evaluate the occurrence of joint symptoms after the outbreak. METHODS: The authors conducted a controlled, population-based questionnaire survey to study the occurrence of joint symptoms within 8 weeks after the exposure. The survey covered three areas: contaminated and uncontaminated parts of the town and a control town. A total of 1000 residents were randomly selected from each area, and the joint symptoms were first analysed separately and thereafter categorized as arthritis-like if joint swelling, redness, warmth or pain in movement was reported. RESULTS: A total of 2123 responses could be evaluated. The overall prevalence of joint symptoms was 13.9% in the contaminated group, 4.3% in the uncontaminated group and 1.5% among the control group, and the frequency of arthritis-like symptoms in the groups was 6.7, 2.1 and 0.5%, respectively. Gastrointestinal symptoms predicted joint complaints, diarrhoea and blood in faeces being the most significant. Residing in the contaminated area was associated with any joint symptom [odds ratio (OR) = 4.0, 95% CI 1.8, 9.0] and joint pain (OR = 7.3, 95% CI 2.1, 24.8) without preceding gastroenteritis. CONCLUSION: The frequency of joint symptoms was high in the contaminated group and also increased in the uncontaminated group. Furthermore, the risk of joint symptoms was increased in the contaminated group even without gastroenteritis.

Secular trend in candidemia and the use of fluconazole in Finland, 2004-2007.

BACKGROUND: In a previous study we observed an increasing trend in candidemia in Finland in the 1990s. Our aim was now to investigate further population-based secular trends, as well as outcome, and evaluate the association of fluconazole consumption and prophylaxis policy with the observed findings. METHODS: We analyzed laboratory-based surveillance data on candidemia from the National Infectious Diseases Register during 2004-2007 in Finland. Data on fluconazole consumption, expressed as defined daily doses, DDDs, was obtained from the National Agency for Medicines, and regional prophylaxis policies were assessed by a telephone survey. RESULTS: A total of 603 candidemia cases were identified. The average annual incidence rate was 2.86 cases per 100,000 population (range by year, 2.59-3.09; range by region, 2.37-3.85). The highest incidence was detected in males aged >65 years (12.23 per 100,000 population). Candida albicans accounted for 67% of cases, and C. glabrata ranked the second (19%), both without any significant change in proportions. C. parapsilosis accounted for 5% of cases and C. krusei 3% of cases. The one-month case-fatality varied between 28-32% during the study period. Fluconazole consumption increased from 19.57 DDDs per 100,000 population in 2000 to 25.09 in 2007. Systematic fluconazole prophylaxis was implemented for premature neonates, patients with acute leukemias and liver transplant patients. CONCLUSION: The dominant proportion of C. albicans remained stable, but C. glabrata was the most frequent non-albicans species. The proportion of C. glabrata had increased from our previous study period in the presence of increasing use of fluconazole. The rate of candidemia in Finland is still low but mortality high like in other countries.

Healthcare associated infection: novel strategies and antimicrobial implants to prevent surgical site infection.

This report is based on a Hygienist Panel Meeting held at St Anne's Manor, Wokingham on 24-25 June 2009. The panel agreed that greater use should be made of antiseptics to reduce reliance on antibiotics with their associated risk of antibiotic resistance. When choosing an antiseptic for clinical use, the Biocompatibility Index, which considers both the microbiocidal activity and any cytotoxic effects of an antiseptic agent, was considered to be a useful tool. The need for longer and more proactive post-discharge surveillance of surgical patients was also agreed to be a priority, especially given the current growth of day-case surgery. The introduction of surgical safety checklists, such as the World Health Organization's Safe Surgery Saves Lives initiative, is a useful contribution to improving safety and prevention of SSIs and should be used universally. Considering sutures as 'implants', with a hard or non-shedding surface to which micro-organisms can form biofilm and cause surgical site infections, was felt to be a useful concept.

Incidence of prosthetic joint infections after primary knee arthroplasty.

We report the 1-year incidence of postoperative infections in an unselected series of 2647 consecutive primary knee arthroplasties (3137 knees) performed in a modern specialized hospital dedicated solely to joint arthroplasty surgery in 2002 to 2006. The rates of superficial and prosthetic joint infections were 2.9% and 0.80%, respectively. Prospective surveillance by hospital infection register failed to detect 6 of the 24 prosthetic joint infections. Increased rate of prosthetic joint infections was associated with complex surgery and with several patient-related factors, for example, comorbidity, obesity, and poor preoperative clinical state. The rate of prosthetic joint infections in contemporary knee arthroplasty is low and mainly related to patient-related factors, of which patient comorbidity has the most profound effect on the infection rate.

Obesity and smoking are factors associated with poor prognosis in patients with bacteraemia.

BACKGROUND: Bacteraemia is still a major cause of case fatality in all age groups. Our aim was to identify the major underlying conditions constituting risk factors for case fatality in bacteraemia patients. METHODS: The study involved 149 patients (79 male and 70 female) with bacteraemia caused by Staphylococcus aureus (S. aureus) (41 patients), Streptococcus pneumoniae (Str. pneumoniae) (42 patients), beta-hemolytic streptococcae (beta-hml str.) (23 patients) and Eschericia coli (E. coli) (43 patients). Underlying diseases, alcohol and tobacco consumption and body mass index (BMI) were registered. Laboratory findings and clinical data were registered on admission and 6 consecutive days and on day 10-14. Case fatality was studied within 30 days after positive blood culture. Associations between underlying conditions and case fatality were studied in univariate analysis and in a multivariate model. RESULTS: Nineteen patients (12.8%) died of bacteraemia. We found obesity (p = 0.002, RR 9.8; 95% CI 2.3 to 41.3), smoking (p < 0.001, RR 16.9; 95% CI 2.1 to 133.5), alcohol abuse (p = 0.008, RR 3.9; 95% CI 1.3 to 11.28), COPD (p = 0.01, RR 8.4; 95% CI 1.9 to 37.1) and rheumatoid arthritis (p = 0.045, RR 5.9; 95% CI 1.2 to 28.8) to be significantly associated with case fatality in bacteraemia in univariate model. The median BMI was significantly higher among those who died compared to survivors (33 vs. 26, p = 0.003). Obesity and smoking also remained independent risk factors for case fatality when their effect was studied together in a multivariate model adjusted with the effect of alcohol abuse, age (continuos variable), sex and causative organism. CONCLUSION: Our results indicate that obesity and smoking are prominent risk factors for case fatality in bacteraemic patients. Identification of risk factors underlying fatal outcome in bacteraemia may allow targeting of preventive efforts to individuals likely to derive greatest potential benefit.

Electrocardiographic abnormalities in patients with diphtheria: a prospective study.

PURPOSE: To determine the incidence of and risk factors for electrocardiographic (ECG) abnormalities in adults with diphtheria. METHODS: A prospective study was conducted involving 122 adult patients with respiratory tract diphtheria. Diphtheria was confirmed by isolation of a toxin-producing strain of Corynebacterium diphtheriae. Patients had serial clinical evaluations and ECGs for a minimum of 21 days. RESULTS: Cardiac involvement was detected in 25 (28%) of 88 evaluable patients, with a median time from symptom onset to an abnormal ECG of 9 days (range, 4 to 24 days). In a logistic regression analysis, age (odds ratio [OR] = 4.1; 95% confidence interval [CI]: 1.6 to 11.0), shared accommodation (OR = 2.9; 95% CI: 1.0 to 8.6), fever (OR = 4.2; 95% CI: 1.1 to 16.6), and extensive respiratory tract infection with subcutaneous edema (OR = 7.0; 95% CI: 1.2 to 42.2) were independent risk factors for cardiac involvement. CONCLUSION: Cardiac involvement is a common complication of respiratory tract infection with C. diphtheriae, and occurs more often among older patients, those with lower socioeconomic status, and those with severe respiratory tract involvement.