Increase in Childhood Nontuberculous Mycobacterial Infections After Bacille Calmette-Guerin Coverage Drop : A Nationwide, Population-Based Retrospective Study, Finland, 1995-2016

Background. Epidemiological data on childhood nontuberculous mycobacterial (NTM) disease is scarce and the protective effect of bacille Calmette-Guerin (BCG) vaccination remains debated. In 2006, the BCG policy in Finland changed from universal to selective. We aimed to study the effect of the BCG coverage decrease on the incidence of childhood NTM infections in Finland. Methods. We conducted a nationwide, population-based, retrospective study of NTM notifications recorded to the National Infectious Diseases Register between 1995 and 2016 and identified native-born children aged 0-4 years infected with NTM. Poisson log-linear model was used to estimate the change in the incidence rate of cohorts born during universal or selective BCG policy between 1995 and 2015. Results. We identified 97 native-born children aged Conclusions. After infant BCG coverage in Finland decreased, childhood NTM infections increased drastically. As there is no other apparent cause for the increase, this indicates that BCG offers protection against childhood NTM disease. 'phis observation adds to the understanding of childhood NTM epidemiology and might explain why the disease is emerging in some countries.Peer reviewe

Multidrug-resistant tuberculosis in Finland : treatment outcome and the role of whole-genome sequencing

Treatment of multidrug-resistant tuberculosis (MDR-TB) is a global challenge requiring long treatment with costly drugs. We assessed treatment combinations, outcome and the utility of whole-genome sequencing (WGS) in MDR-TB cases.Clinical, demographic and microbiological data were obtained of all patients with MDR-TB who started treatment in Finland in 2007-2016. Definitions of MDR, pre-extensively drug-resistant (pre-XDR) and XDR tuberculosis were those applicable at the study period. Treatment outcome was defined according to World Health Organization (WHO) guidelines. Mycobacterium tuberculosis isolates were analysed by WGS in addition to routinely performed phenotypic drug susceptibility testing and genotyping. Among the 47 cases, 35 (74%) had a successful treatment outcome. Risk factors for non-successful outcome were Finnish origin and XDR. Almost 90% of our cases had an adverse event for at least one drug. Phenotypic and WGS drug resistance results were fully concordant for isoniazid, fluoroquinolones and amikacin, and >90% concordant for rifampicin, pyrazinamide, kanamycin and capreomycin. >60% of phenotypically ethambutol-susceptible isolates were genotypically resistant. The results of the rifampicin and isoniazid nucleic acid amplification tests (NAATs) performed for the isolates were identical to the WGS results except for three isolates having uncommon resistance mutations not included in the NAATs. WGS did not reveal unexpected clustering.More training is needed for physicians treating MDR-TB, and especially XDR-TB, to improve treatment outcome. Phenotypic drug susceptibility testing was shown to be unreliable for ethambutol. WGS could aid in the selection of optimal treatment regimen in the future.Peer reviewe

Epidemiology and outcome of HIV patients in Finland co-infected with tuberculosis 1998-2015

Background: Tuberculosis (TB) is a major cause of death in HIV patients worldwide. Here we describe the epidemiology and outcome of HIV-TB co-infections in a high-income country with low TB incidence and integrated HIV and TB therapy according to European guidelines. Methods: This study was based on the HIV cohort of the Helsinki University Hospital which includes all HIV patients in the Helsinki region with a population of 1.5 million. Totally, 1939 HIV-positives who have been under follow-up between 1998 and 2015 were included. Results: TB was diagnosed in 53 (2.7%) of the HIV-patients. The TB incidence rate was higher in injecting drug users (IRR 3.15; 95% CI 1.33-7.52) and heterosexuals (IRR 3.46; 95% CI 1.64-7.29) compared to men having sex with men. The incidence rate was also higher in those born in Sub-Saharan Africa (IRR 3.53; 95% CI 1.78-7.03) compared to those born in Finland. There was a significant reduction in the total TB incidence rate of 59% per 6-year period between 1998 and 2015 (p <0.001). In injecting drug users there was a reduction in incidence rate from 1182 to 88 per 100,000 (p <0.001) and in people born in Sub-Saharan Africa from 2017 to 195 per 100,000 (p <0.001). Among the 53 HIV-TB co-infected cases, one female and 15 males died during follow up. HIV was the primary cause of death in five patients but none of the deaths were caused by TB. Conclusion: The incidence rate of tuberculosis among HIV-positives in Finland has been declining between 1998 and 2015. Among injecting drug users, the reduction is probably explained by harm reduction interventions and care in comprehensive care centers in Helsinki. The increased coverage of antiretroviral therapy is probably another main reason for the decline in TB incidence rates. Despite good treatment results for both HIV and TB, the all-cause mortality among Finnish males with HIV-TB was high, and common causes of death were intoxications and suicides.Peer reviewe

Paediatric tuberculosis during universal and selective Bacillus Calmette-Guerin vaccination policy : a nationwide population-based retrospective study, Finland, 1995-2015

Introduction: In 2006, the Bacillus Calmette-Guerin (BCG) vaccination policy in Finland changed from universal to selective. Aim: We assessed the impact of the policy change on tuberculosis (TB) morbidity in children under 5 years and epidemiological trends of paediatric TB in Finland. Methods: We conducted a nationwide, population-based, retrospective registry study of all newly diagnosed active TB cases younger than 15 years in Finland from 1995 to 2015 by linking data from the National Infectious Diseases Register, Finnish Care Register for Health Care, medical patient records and Finnish Population Information System. We compared the TB incidence rate ratio of under 5 year-olds with universal and selective BCG vaccinations with a Poisson log-linear model and analysed incidence trends among those younger than 15 years with a negative binomial model. Results: We identified 139 paediatric TB cases: 50 native (including 24 second-generation migrants) and 89 foreign-born children. The TB rate of under 5 year-olds remained stable after changing to selective BCG vaccination (incidence rate ratio (IRR): 1.3; 95% confidence interval (CI): 0.72.3). TB rate in the native population under 15 years increased slightly (IRR = 1.06; 95% CI: 1.01-1.11). Discussion: Paediatric TB cases in Finland were concentrated in families with migrant background from high-TB incidence countries. The native TB morbidity in under 5-year-olds did not increase after the BCG policy revision, suggesting that selective vaccinations can prevent TB in the most vulnerable age group in low-incidence settings. Second-generation migrants under 15 years in Finland with high TB risk are probably increasing.Peer reviewe

Kirjatun työkykytiedon tärkeys ja hyödyllisyys työterveyshuollossa – kyselytutkimus työterveyshuollon ammattilaisille

In order to prolong working careers, it is essential that the signs of weak work ability are noticed, and the support of work ability are started as early as possible. The electronic patient records play a important role in this, such as how structurally the patient data has been documented. According to the Health Care Act (1326/2010), municipalities shall monitor the health and welfare of their residents. The data play a key role in this, also. The purpose of the study is to find out the importance of work ability data, its' documentation method in electronic health records, and the suitability for national population-level monitoring data. The research material was collected in December 2019 with an e-mail survey that contained statements related to work ability data to be documented. The questionnaire was sent to 332 occupational health professionals, of whom 91 responded. The important work ability data were mental and physical performance, work disability time, patient's and professional's assessments of work ability, work stress factors, and a plan for returning to work. The majority of respondents used work ability data in patient care and believed the data would also be useful to other health care professionals. The most appropriate national follow-up data among work ability data were the diagnosis of the disease or the reasons for treatment, health risk, work disability time, and patient's and professional's assessments of work ability. The most common way on documentation of work ability data in electronic health records was free form. In utilization of the patient data, everything is depending on the documentation. The patient data must be uniformly defined, and structured, and electronic health records must enable the documentation as smoothly as possible as part of the health care professionals' reception processes. Also, for the population-level monitoring, data should be collected from there, where it naturally arises as part of patient care.Työurien pidentämisessä oleellista on, että työkyvyn heikkenemisen merkit havaitaan terveydenhuollossa mahdollisimman varhain, jotta työkyvyn tuen toimenpiteet voidaan aloittaa mahdollisimman oikea-aikaisesti. Tässä tärkeä rooli on potilastietojärjestelmillä, joiden hyödyntämiseen vaikuttaa, kuinka rakenteisesti tiedot on niihin kirjattu. Terveydenhuoltolain (1326/2010) mukaan kunnan on seurattava asukkaittensa terveyttä ja hyvinvointia sekä niihin vaikuttavia tekijöitä väestöryhmittäin. Keskeisessä asemassa siinäkin on tieto. Tutkimuksen tarkoituksena on selvittää työterveyshenkilöstön näkemyksiä työkykytiedon tärkeydestä ja hyödyllisyydestä potilastyössä, kirjaamistavasta potilastietojärjestelmässä sekä sopivuudesta valtakunnalliseksi väestötason seurantatiedoksi. Tutkimusaineisto kerättiin joulukuussa 2019 sähköpostikyselyllä, joka sisälsi asenneväittämiä kirjattavista työkykytiedoista. Kysely lähetettiin 332 työterveyshuollon ammattilaiselle, joista kyselyyn vastasi 91 henkilöä. Tärkeinä työkykytietoina pidettiin psyykkistä ja fyysistä suorituskykyä, työkyvyttömyysaikaa, potilaan ja ammattilaisten arvioita työkyvystä, työn kuormitustekijöitä sekä työhön paluun suunnitelmaa. Suurin osa vastaajista kertoi hyödyntävänsä työkykytietoja potilastyössään ja uskoi tietojen olevan hyödyllisiä myös muille potilasta hoitaville terveydenhuollon ammattilaisille. Työkykytiedoista sopivimpia kansallisiksi työkykyä kuvaaviksi seurantatiedoiksi olivat sairauden diagnoosi tai hoidon syy, terveysriski, työkyvyttömyysaika sekä potilaan ja ammattilaisen arviot työkyvystä. Potilastietojärjestelmissä yleisin kirjaamistapa työkykytiedoille oli vapaamuotoinen. Tiedon hyödyntämisessä kaikki lähtee kirjaamisesta. Tiedon pitää olla yhtenäisesti määriteltyä ja rakenteista. Lisäksi potilastietojärjestelmien tulee mahdollistaa tiedon kirjaaminen mahdollisimman sujuvasti osana vastaanoton kulkua. Myös väestötasoista seurantaa varten tulisi tieto kerätä sieltä, missä se luonnollisesti syntyy osana asiakas- ja potilastyötä

Kanta-arkiston käyttökokemuksia työterveyshuollossa

The purpose of the eHealth and eSocial Strategy 2020 by the Finnish Ministry of Social Affairs and Health is to provide health care professionals with access to up-to-date patient data and information systems that support their work. Patient data are exchanged between organizations using the national Patient Data Repository (Kanta repository). The repository is increasingly used by the health care professionals as well as citizens. Presently, patient data of nearly every Finn are stored in it. The purpose of this study was to determine the use of the Kanta repository in Occupational Health Services using an electronic questionnaire in summer 2017. The survey targeted occupational health physicians, nurses, physiotherapists, and psychologists. There was a total of 359 respondents. The results indicate that the Kanta repository is positively viewed but not used extensively. Respondents say that patient data retrieval is slow, the required data cannot be found with certainty and occasionally, there are some delays with saving patient data in the Kanta repository. Furthermore, the dates of patient visits showed in the Kanta repository do not always correspond to the actual dates of the visits. Occupational health professionals believe that other professionals utilize patient data generated in occupational health services. However, they feel that getting an overall status of a patient’s care is not easy with the Kanta repository. Documenting and archiving patient data without delay in the Kanta repository provides patients with the best care possible, as professionals can access the patient’s entire medical history if necessary. Although using the Kanta repository is still somewhat cumbersome and there are difficulties with finding patient data, it fulfils its purpose and supports the occupational health professionals’ work. In the future, the situation will hopefully improve. The national patient data management service of the Kanta repository will start providing professionals with the summaries of patient’s key structural health information.Sosiaali- ja terveysministeriön laatiman Sote-tieto hyötykäyttöön -strategian tarkoituksena on mahdollistaa, että terveydenhuollon ammattilaisella on käytössään ajantasainen potilastieto ja työtä tukevat tietojärjestelmät. Tietojen vaihto yli organisaatiorajojen toteutetaan valtakunnallisen Potilastiedon arkiston (Kanta-arkiston) avulla. Arkistoon on tallennettu tietoja lähes kaikista suomalaisista ja sen käyttö lisääntyy terveydenhuollon ammattilaisten keskuudessa koko ajan. Tutkimuksen tarkoituksena oli selvittää Kanta-arkiston käyttöä työterveyshuollossa. Sähköinen kysely lähetettiin työterveyslääkäreille, työterveyshoitajille, työfysioterapeuteille ja työterveyspsykologeille kesällä 2017 ja siihen vastasi yhteensä 359 henkilöä. Tulokset osoittavat, että Kanta-arkistoa pidetään hyvänä ideana, mutta sitä käytetään vielä vähän. Vastaajat kokevat, että tietojen haku on hidasta, tarvittavan tiedon löytäminen hankalaa ja potilastietojen tallentumisessa Kanta-arkistoon on ajoittain viivettä. Lisäksi Kanta-arkistossa näkyvät potilaskäyntien päivämäärät eivät aina välttämättä vastaa käynnin todellista ajankohtaa. Työterveyshuollon ammattilaiset uskovat muiden ammattilaisten hyödyntävän työterveyshuollossa syntyneitä tietoja, vaikka kokevatkin, että Kanta-arkiston avulla kokonaiskuvan saaminen potilaan hoidon tilanteesta ei onnistu helposti. Tietojen ajantasainen kirjaaminen ja niiden tallentuminen Kanta-arkistoon mahdollistaa potilaalle parhaan mahdollisen hoidon, kun ammattilaiset saavat tarvittaessa esille potilaan koko terveys- ja sairaushistorian. Vaikka Kanta-arkiston käyttö on vielä osin hankalaa ja tietojen löytämisessä on vaikeutta, voidaan kuitenkin sanoa sen täyttävän tarkoituksensa ja hyödyttävän työterveyshuollon ammattilaisen työtä. Tulevaisuudessa tilanne tulee paranemaan, kun Kanta-arkistoon toteutettavan tiedonhallintapalvelun kautta saadaan ammattilaisille käyttöön kooste potilasta koskevista keskeisistä terveystiedoista

Risk factors affecting treatment outcomes for pulmonary tuberculosis in Finland 2007-2014: a national cohort study

BackgroundMajor transition in tuberculosis (TB) epidemiology is taking place in many European countries including Finland. Monitoring treatment outcome of TB cases is important for identifying gaps in the national TB control program, in order to strengthen the system. The aim of the study was to identify potential risk factors for non-successful TB treatment outcomes, with a particular focus on the impact of comorbidities. We also evaluated the treatment outcome monitoring system.MethodsAll notified microbiologically confirmed pulmonary TB cases in Finland in 2007-2014 were included, except multi-drug resistant (MDR) cases. Nationwide register data were retrieved from: Infectious Diseases Register, Population Register, Cause of Death Register and Hospital Discharge Register. Non-successful outcomes were divided into three groups: death, unsatisfactory outcomes and non-defined outcomes. Logistic regression analyses were used to identify risk factors for non-successful outcomes.ResultsTreatment outcomes were notified for 98.6% of study cases (n =1396/1416). Treatment success rate was 75%. The main reason for non-successful outcome was death (16%), whereas outcomes failed and lost to follow-up were rare (1% together). In a multivariable model, risk factors for death as outcome were increasing age, male gender and Charlson comorbidity index >= 1, for unsatisfactory outcomes non-MDR drug resistance and TB registered in the first study period, and for non-defined outcomes non-MDR drug resistance. Among 50 cases with unsatisfactory outcomes, we observed false outcome allocations in eight (16%), and>2% of the cases transferred to another country or disappeared before or during treatment.ConclusionsWith a high proportion of older population among tuberculosis cases, death is a common treatment outcome in Finland. Comorbidity is an important factor to be incorporated when interpreting and comparing outcome rates. There was a considerable inconsistency in outcome allocation in the monitoring system, which implies that there is need to review the guidelines and provide further training for outcome assessment