Induced abortions of women living with HIV in Finland 1987-2019: a national register study

BACKGROUND

Recent data on the rate and risk factors of induced abortion among women living with HIV (WLWH) are limited. Our aim was to use Finnish national health register data to 1) determine the nationwide rate of induced abortions of WLWH in Finland during 1987-2019, 2) compare the rates of induced abortions before and after HIV diagnosis over different time periods, 3) determine the factors associated with terminating a pregnancy after HIV diagnosis, and 4) estimate the prevalence of undiagnosed HIV at induced abortions to see whether routine testing should be implemented.

METHODS

A retrospective nationwide register study of all WLWH in Finland 1987-2019 (n = 1017). Data from several registers were combined to identify all induced abortions and deliveries of WLWH before and after HIV diagnosis. Factors associated with terminating a pregnancy were assessed with predictive multivariable logistic regression models. The prevalence of undiagnosed HIV at induced abortion was estimated by comparing the induced abortions among WLWH before HIV diagnosis to the number of induced abortions in Finland.

RESULTS

Rate of induced abortions among WLWH decreased from 42.8 to 14.7 abortions/1000 follow-up years from 1987-1997 to 2009-2019, more prominently in abortions after HIV diagnosis. After 1997 being diagnosed with HIV was not associated with an increased risk of terminating a pregnancy. Factors associated with induced abortion in pregnancies that began after HIV diagnosis 1998-2019 were being foreign-born (OR 3.09, 95% CI 1.55-6.19), younger age (OR 0.95 per year, 95% CI 0.90-1.00), previous induced abortions (OR 3.36, 95% CI 1.80-6.28), and previous deliveries (OR 2.13, 95% CI 1.08-4.21). Estimated prevalence of undiagnosed HIV at induced abortion was 0.008-0.029%.

CONCLUSIONS

Rate of induced abortions among WLWH has decreased. Family planning should be discussed at every follow-up appointment. Routine testing of HIV at all induced abortions is not cost-effective in Finland due to low prevalence.

Multi-drug resistant tuberculosis in Finland; treatment outcome and the role of whole genome sequencing

Treatment of multi-drug 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 TB (pre-XDR) and XDR-TB were those applicable at the study period. Treatment outcome was defined according to WHO guidelines.M. tuberculosisisolates 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 ninety percent 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. More than 60% of phenotypically ethambutol susceptible isolates were genotypically resistant. The results of the rifampicin and isoniazid NAA tests 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. Phenotypical drug susceptibility testing was shown to be unreliable for ethambutol. WGS can aid in the selection of optimal treatment regimen in the future.

Phylogenetic Estimation of the Viral Fitness Landscape of HIV-1 Set-Point Viral Load

Set-point viral load (SPVL), a common measure of human immunodeficiency virus (HIV)-1 virulence, is partially determined by viral genotype. Epidemiological evidence suggests that this viral property has been under stabilising selection, with a typical optimum for the virus between 10⁴ and 10⁵ copies of viral RNA per ml. Here we aimed to detect transmission fitness differences between viruses from individuals with different SPVLs directly from phylogenetic trees inferred from whole-genome sequences. We used the local branching index (LBI) as a proxy for transmission fitness. We found that LBI is more sensitive to differences in infectiousness than to differences in the duration of the infectious state. By analysing subtype-B samples from the Bridging the Evolution and Epidemiology of HIV in Europe project, we inferred a significant positive relationship between SPVL and LBI up to approximately 10⁵ copies/ml, with some evidence for a peak around this value of SPVL. This is evidence of selection against low values of SPVL in HIV-1 subtype-B strains, likely related to lower infectiousness, and perhaps a peak in the transmission fitness in the expected range of SPVL. The less prominent signatures of selection against higher SPVL could be explained by an inherent limit of the method or the deployment of antiretroviral therapy.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Finnish HIV Quality of Care Register (FINHIV)

PURPOSE

The Finnish HIV Quality of Care Register (FINHIV) was created to: (1) estimate the number of people living with HIV (PLWH) in Finland, (2) evaluate the national level of antiretroviral medication use and viral suppression, (3) examine the change in the HIV epidemic in Finland to pinpoint issues to address and (4) enable evaluation of the health of the PLWH by combining the FINHIV data with other national healthcare data.

PARTICIPANTS

The FINHIV includes all people diagnosed or being treated for HIV infection in Finland since 1984. The register was formed in 2020 by combining data from the National Infectious Diseases Register (information from time of diagnosis, data from 1984) and from the 21 HIV Clinics that treat HIV-positive patients in Finland (earliest data from 1998). The register population forms a nationwide, open cohort with yearly updates; currently it consists of 4218 PLWH (including 718 deceased) with HIV diagnosed or treated in Finland 1984-2019. Current rate of new cases is 150 cases/year.

FINDINGS TO DATE

From the FINHIV data, we can confirm that Finland has reached the Joint United Nations Programme for HIV/AIDS (UNAIDS) 90-90-90 targets set for 2020, and that the proportion of virally suppressed is constant between all 21 HIV Clinics in Finland, despite their varying size. Linkage to care is estimated at 94.3% of those diagnosed. In contrast to the treatment results, more than half of the PLWH have been diagnosed at a late stage, and the proportion has increased since 2000.

FUTURE PLANS

Combinations of FINHIV data with other national healthcare register data in Finland will provide further information on other aspects of the health of the PLWH in a high-resource setting (eg, comorbidities, sexual health and use of healthcare resources). Additionally, implementation of patient-reported experience and outcome measures within the FINHIV is ongoing.

Liver Fat, Adipose Tissue, and Body Composition Changes After Switching from a Protease Inhibitor or Efavirenz to Raltegravir

Integrase inhibitors appear to increase body weight, but paradoxically some data indicate that raltegravir (RAL) may decrease liver fat. Our objective was to study the effects of switching from a protease inhibitor (PI) or efavirenz (EFV) to RAL on liver fat, body composition, and metabolic parameters among people living with HIV (PLWH) with high risk for nonalcoholic fatty liver disease (NAFLD). We randomized overweight PLWH with signs of metabolic syndrome to switch a PI or EFV to RAL (n = 19) or to continue unchanged antiretroviral therapy (control, n = 24) for 24 weeks. Liver fat was measured by magnetic resonance spectroscopy (MRS), body composition by magnetic resonance imaging, and bioimpedance analysis; subcutaneous fat biopsies were obtained. Median (interquartile range) liver fat content was normal in RAL 2.3% (1.1-6.0) and control 3.1% (1.6-7.3) group at baseline. Liver fat and visceral adipose tissue remained unchanged during the study. Body weight [from 85.9 kg (76.1-97.7) to 89.3 (78.7-98.7), p = 0.019], body fat mass [from 20.3 kg (14.6-29.7) to 22.7 (17.0-29.7), p = 0.015], and subcutaneous adipose tissue (SAT) volume [from 3979 mL (2068-6468) to 4043 (2206-6433), p = 0.048] increased, yet, adipocyte size [from 564 pL (437-733) to 478 (423-587), p = 0.019] decreased in RAL but remained unchanged in control group. Circulating lipids and inflammatory markers improved in RAL compared to control group. The median liver fat measured by MRS was unexpectedly within normal range in this relatively small study population with presumably high risk for NAFLD contradicting high prevalence of NAFLD reported with other methods. Despite weight gain, increase in SAT together with decreased adipocyte size and reduced inflammation may reflect improved adipose tissue function. Clinical Trial Registration number: NCT03374358.

Prevalence of obesity and disturbances in glucose homeostasis in HIV-infected subjects and general population - missed diagnoses of diabetes?

Objectives

Comparative data on glucose disorders using fasting blood samples between people living with HIV (PLWH) and the general population are lacking. The objective of this study was to compare the prevalence and risk factors of obesity and disturbances in glucose homeostasis between PLWH treated with modern antiretroviral therapy and the general population.

Methods

Adjusted prevalence of obesity, features of insulin resistance (triglyceride:high‐density lipoprotein cholesterol ratio and alanine aminotransferase), impaired fasting glucose (IFG), diabetes mellitus (DM) and combined dysglycaemia (presence of IFG or DM) were determined using fasting blood samples among 1041 PLWH and 7047 subjects representing the general population.

Results

People living with HIV had a lower prevalence of obesity [18.2%, 95% confidence interval (CI): 15.1–21.2 vs. 23.9%, 95% CI: 22.4–25.4], but a higher prevalence of insulin resistance and IFG (20.0%, 95% CI: 16.6–23.4 vs. 9.8%, 95% CI: 8.7–10.8) than the general population. Fasting glucose concentration was higher, but glycated haemoglobin (HbA1c) was lower, among PLWH. Prevalence of dysglycaemia for a given body mass index (BMI) was higher in PLWH than in the general population. The prevalence of DM did not differ between PLWH (13.2%, 95% CI: 10.2–15.9) and the general population (14.5%, 95% CI: 13.6–15.4).

Conclusions

The prevalence of obesity was lower, but the risk of dysglycaemia for a given BMI was significantly higher, among PLWH, highlighting the importance of prevention and treatment of obesity among HIV‐infected subjects. Regardless of the increased prevalence of insulin resistance and IFG, DM was surprisingly not more common among PLWH, raising concern about the under‐diagnosis of DM, possibly due to low sensitivity of HbA1c in this patient population.

Switching from Tenofovir Disoproxil Fumarate to Tenofovir Alafenamide Significantly Worsens the Lipid Profile in a Real-World Setting

Tenofovir disoproxil fumarate (TDF) has increasingly been replaced by tenofovir alafenamide (TAF) because of reduced kidney and bone toxicity with TAF. This switch has, however, caused worsening of lipid concentrations in clinical trials, but data from any real-world setting are scarce. The objective of this study was to characterize the effect of TDF to TAF switch on plasma lipid concentrations in a real-world clinic population. This is a retrospective study comparing lipid concentrations and other laboratory parameters between the last visit on TDF and the first visit after at least a 2-month exposure to TAF. A total of 490 HIV-positive subjects were included in the study. The median (interquartile range) increase was 23.2 (0-38.7) mg/dL in total cholesterol (p < 0.001) and 15.5 (0-30.9) mg/dL in low-density lipoprotein (LDL) cholesterol (p < 0.001). The ratio of total cholesterol to high-density lipoprotein (HDL) cholesterol increased by 0.2 (-0.2 to 0.6), p < 0.001. The proportion of patients having optimal LDL cholesterol concentration by National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) decreased from 30.8% to 17.8% and proportion having dyslipidemia or severe dyslipidemia increased from 30.2% to 50.3% after the switch. Demographic characteristics, antiretroviral agents, or comedication did not affect the changes in lipid concentrations. Plasma creatinine decreased by 0.03 (-0.09 to 0.03) mg/dL (p < 0.001) and estimated glomerular filtration rate increased by 0.5 (-2.3 to 3.2) mL/min (p = 0.009). Switching from TDF to TAF caused a statistically significant worsening of the lipid profile that may have clinical relevance. The benefit of the lipid-lowering effect of TDF should be considered in selected patients with low risk for kidney and bone toxicity.

Kaposi sarcoma in Southern Finland (2006-2018)

BACKGROUND

Kaposi sarcoma (KS) age-standardized incidence rate is below 0.3 per 100,000 in Nordic countries. Data on KS in Finland have been sparse.

METHODS

A retrospective review of all the patients with KS cases managed in the Helsinki University Central Hospital between 2006 and 2018.

RESULTS

Forty patients (median age at diagnosis 45 years, 38 males) were included. About 2.5 new cases were diagnosed per year (incidence 0.16 /100,000). The different subtypes of KS were: human immunodeficiency virus (HIV) (65%), classical KS (30%), and immunodepression (5%). Patients with HIV were significantly younger, more likely to have cutaneous lesions of the face, the trunk, and mucosal lesions, and KS within lymph nodes and inner organs. KS was diagnosed at the same time as HIV in 77% of cases, 28% with CD4-cell level above 300 cells/mm³ . Among the patients with classical KS (n = 12), 75% were of Finnish origin, 41% had a second primary malignancy diagnosed, and 25% had noninsulin dependent diabetes mellitus. Among HIV patients, 27% had another AIDS-related illness, 7% of the patients developed lymphoproliferative disorders, and 7% a hemophagocytic syndrome. Patients with HIV were always treated with antiviral therapy, with pegylated liposomal doxorubicin in 57% of the cases. Local radiotherapy was the main treatment for other KS types. None of the 5 deaths during follow-up was related to KS.

CONCLUSIONS

Classical KS (KS-CLA) occurs among native Finns, frequently with other present malignancies. Screening of HIV and other malignancies is warranted in new cases of KS.

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.

Important Gaps in HIV Knowledge, Attitudes and Practices Among Young Asylum Seekers in Comparison to the General Population

Migrants are disproportionately affected by HIV in many European countries, including Finland. We aimed to compare the HIV-related knowledge, attitudes and practices (KAP) of young asylum seekers to those of the general young adult population. Two cross-sectional surveys were conducted among 20- to 25-year-old young adults: The TIE study among asylum seekers (n = 47) and the World AIDS Day 2014 study among the general population (n = 485). Important gaps in HIV KAP were identified especially among the young asylum seekers. For the general young adult population, previous HIV testing was associated with female gender, better HIV knowledge and increased sexual activity. Health education concerning HIV needs to be further enforced among young adults in Finland. Due to poorer HIV knowledge, young asylum seekers might be especially vulnerable to HIV. The asylum process is a window of opportunity for health education and HIV testing.

Easy and accurate reconstruction of whole HIV genomes from short-read sequence data with shiver

Studying the evolution of viruses and their molecular epidemiology relies on accurate viral sequence data, so that small differences between similar viruses can be meaningfully interpreted. Despite its higher throughput and more detailed minority variant data, next-generation sequencing has yet to be widely adopted for HIV. The difficulty of accurately reconstructing the consensus sequence of a quasispecies from reads (short fragments of DNA) in the presence of large between- and within-host diversity, including frequent indels, may have presented a barrier. In particular, mapping (aligning) reads to a reference sequence leads to biased loss of information; this bias can distort epidemiological and evolutionary conclusions. De novo assembly avoids this bias by aligning the reads to themselves, producing a set of sequences called contigs. However contigs provide only a partial summary of the reads, misassembly may result in their having an incorrect structure, and no information is available at parts of the genome where contigs could not be assembled. To address these problems we developed the tool shiver to pre-process reads for quality and contamination, then map them to a reference tailored to the sample using corrected contigs supplemented with the user's choice of existing reference sequences. Run with two commands per sample, it can easily be used for large heterogeneous data sets. We used shiver to reconstruct the consensus sequence and minority variant information from paired-end short-read whole-genome data produced with the Illumina platform, for sixty-five existing publicly available samples and fifty new samples. We show the systematic superiority of mapping to shiver's constructed reference compared with mapping the same reads to the closest of 3,249 real references: median values of 13 bases called differently and more accurately, 0 bases called differently and less accurately, and 205 bases of missing sequence recovered. We also successfully applied shiver to whole-genome samples of Hepatitis C Virus and Respiratory Syncytial Virus. shiver is publicly available from https://github.com/ChrisHIV/shiver.

Most women living with HIV can deliver vaginally-National data from Finland 1993-2013

Introduction

Vaginal delivery has been recommended for more than ten years for women living with HIV (WLWH) with good virological control. However, in Europe most WLWH still deliver by cesarean section (CS). Our aim was to assess the rate of vaginal delivery and the indications for CS in WLWH over 20 years in a setting of low overall CS rate.

Materials and methods

This was a retrospective study of all WLWH delivering in Finland 1993–2013. We identified the women by combining national health registers and extracted data from patient files.

Results

The study comprised 212 women with 290 deliveries. Over 35% of the women delivered several children during the study years. During 2000–2013, with consistent viral load monitoring, 80.0% showed HIV viral loads <50 copies/mL in the last measurement preceding the delivery. Altogether 74.5% of all WLWH delivered vaginally and the rate of both elective CS and emergency CS was 12.8% each. For most CSs (63.5%) the indication was obstetrical, for 28.4% it was avoiding HIV transmission and for 0.7% it was mother’s request. In hospitals with less than ten HIV-related deliveries during the study period, the rate of elective CS was higher than in more experienced hospitals (22.7% versus 10.6% [p = 0.024]). No perinatal HIV transmissions occurred.

Conclusions

Most WLWH can achieve good virological control and deliver vaginally. This will help them to maintain their future child bearing potential and reduce CS-related morbidity.

Missed hepatitis b/c or syphilis diagnosis among Kurdish, Russian, and Somali origin migrants in Finland: linking a population-based survey to the national infectious disease register

BACKGROUND

Migrants are considered a key population at risk for sexually transmitted and blood-borne diseases in Europe. Prevalence data to support the design of infectious diseases screening protocols are scarce. We aimed to estimate the prevalence of hepatitis B and C, human immunodefiency virus (HIV) infection and syphilis in specific migrant groups in Finland and to assess risk factors for missed diagnosis.

METHODS

A random sample of 3000 Kurdish, Russian, or Somali origin migrants in Finland was invited to a migrant population-based health interview and examination survey during 2010-2012. Participants in the health examination were offered screening for hepatitis B and C, HIV and syphilis. Notification prevalence in the National Infectious Diseases Register (NIDR) was compared between participants and non-participants to assess non-participation. Missed diagnosis was defined as test-positive case in the survey without previous notification in NIDR. Inverse probability weighting was used to correct for non-participation.

RESULTS

Altogether 1000 migrants were screened for infectious diseases. No difference in the notification prevalence among participants and non-participants was observed. Seroprevalence of hepatitis B surface antigen (HBsAg) was 2.3%, hepatitis C antibodies 1.7%, and Treponema pallidum antibodies 1.3%. No cases of HIV were identified. Of all test-positive cases, 61% (34/56) had no previous notification in NIDR. 48% of HBsAg, 62.5% of anti-HCV and 84.6% of anti-Trpa positive cases had been missed. Among the Somali population (n = 261), prevalence of missed hepatitis B diagnosis was 3.0%. Of the 324 Russian migrants, 3.0% had not been previously diagnosed with hepatitis C and 2.4% had a missed syphilis diagnosis. In multivariable regression model missed diagnosis was associated with migrant origin, living alone, poor self-perceived health, daily smoking, and previous diagnosis of another blood-borne infection.

CONCLUSIONS

More than half of chronic hepatitis and syphilis diagnoses had been missed among migrants in Finland. Undiagnosed hepatitis B among Somali migrants implies post-migration transmission that could be prevented by enhanced screening and vaccinations. Rate of missed diagnoses among Russian migrants supports implementation of targeted hepatitis and syphilis screening upon arrival and also in later health care contacts. Coverage and up-take of current screening among migrants should be evaluated.

Declining prevalence of cytological squamous intraepithelial lesions of the cervix among women living with well-controlled HIV - Most women living with HIV do not need annual PAP smear screening

INTRODUCTION

Cervical screening by means of annual Papanicolaou (PAP) smears has been recommended for all women living with HIV. We analysed the results of our annual PAP smear screening program to identify low-risk subgroups for less rigorous screening.

MATERIAL AND METHODS

The study comprised 369 women followed at the Helsinki University Hospital 2002-2013, with a total of 2033 PAP smear results. We analyzed the temporal changes in PAP smear findings. Logistic regression analysis for binominal dependent variables was used for assessing risk factors for ever having cytological squamous intraepithelial lesions (hereafter referred as SIL) using generalized estimating equations taking into account multiple observations of each patient.

RESULTS

Most women had well-controlled HIV, especially towards the end of the study. PAP smear results improved substantially. At the time of each individual's last PAP smear, 90.0% of the findings displayed normal results. Conversely, the rate of SIL decreased from 16.8% to 4.6% from 2002 to 2013. In multivariate analysis the risk of SIL was significantly lower in women with consecutive normal PAP smear findings during the first two years of follow up [odds ratio (OR) 0.21, 95% confidence interval (CI) 0.10-0.45, p < 0.001] and with CD4 counts >500 cells/μL (OR 0.11, 95% CI 0.05-0.26, p < 0.001).

CONCLUSIONS

Widespread use of combination antiretroviral therapy (cART) and systematic cervical screening has reduced the rate of abnormal PAP smears. It seems feasible to identify low-risk women by combining HIV-related information and PAP smear results. Screening low-risk women living with HIV at three-year intervals similar to HIV-negative women appears justified.

Viral genetic variation accounts for a third of variability in HIV-1 set-point viral load in Europe

HIV-1 set-point viral load-the approximately stable value of viraemia in the first years of chronic infection-is a strong predictor of clinical outcome and is highly variable across infected individuals. To better understand HIV-1 pathogenesis and the evolution of the viral population, we must quantify the heritability of set-point viral load, which is the fraction of variation in this phenotype attributable to viral genetic variation. However, current estimates of heritability vary widely, from 6% to 59%. Here we used a dataset of 2,028 seroconverters infected between 1985 and 2013 from 5 European countries (Belgium, Switzerland, France, the Netherlands and the United Kingdom) and estimated the heritability of set-point viral load at 31% (CI 15%-43%). Specifically, heritability was measured using models of character evolution describing how viral load evolves on the phylogeny of whole-genome viral sequences. In contrast to previous studies, (i) we measured viral loads using standardized assays on a sample collected in a strict time window of 6 to 24 months after infection, from which the viral genome was also sequenced; (ii) we compared 2 models of character evolution, the classical "Brownian motion" model and another model ("Ornstein-Uhlenbeck") that includes stabilising selection on viral load; (iii) we controlled for covariates, including age and sex, which may inflate estimates of heritability; and (iv) we developed a goodness of fit test based on the correlation of viral loads in cherries of the phylogenetic tree, showing that both models of character evolution fit the data well. An overall heritability of 31% (CI 15%-43%) is consistent with other studies based on regression of viral load in donor-recipient pairs. Thus, about a third of variation in HIV-1 virulence is attributable to viral genetic variation.

A closer look at travellers' infections abroad: Finnish nationwide data with incidences, 2010 to 2012

BACKGROUND

Although infections represent the most common health problem of travellers abroad, data on morbidity and incidences of various infections are scarce.

METHOD

Data on infections of Finnish travellers during 2010-2012 were retrieved from the database of SOS International, an assistance organization covering 95% of Finns requiring aid abroad. The study included 30,086 cases. For incidence calculation, the data were linked to the numbers of Finns visiting these regions during the same period as recorded by the Official Statistics of Finland.

RESULTS

The incidence of infections was particularly high in Africa, southern Europe plus the eastern Mediterranean, and Asia plus Oceania. The most frequent diagnoses were acute gastroenteritis (38.0%) and respiratory-tract infections (RTI) (34.5%), followed by infections of the ear (12.6%), skin or subcutaneous tissue (5.1%), urogenital tract (4.2%), eye (3.1%), and systemic febrile infections (2.2%). Vaccine-preventable diseases (VPD) accounted for 0.8% of cases, with varicella as most (49%) and influenza as second-most (27%) common.

CONCLUSIONS

Incidence of infections was higher in southern than in eastern and western Europe. Gastroenteritis and RTI proved the most frequent diagnoses, whereas systemic febrile infections were uncommon. Despite pre-travel immunizations, VPDs still occurred; pre-travel consultation should cover both varicella and influenza.

Illness and injury of travellers abroad: Finnish nationwide data from 2010 to 2012, with incidences in various regions of the world

Binary file ES_Abstracts_Final_ECDC.txt matches

Imported malaria in Finland 2003-2011: prospective nationwide data with rechecked background information

BACKGROUND

Although described in several reports, imported malaria in Europe has not been surveyed nationwide with overall coverage of patients and individually rechecked background information. Plasmodium falciparum infections have been reported despite regularly taken appropriate chemoprophylaxis, yet the reliability of such questionnaire-based retrospective data has been questioned. This was the starting-point for conducting a prospective nationwide survey of imported malaria where compliance data was double-checked.

METHODS

Data was collected on all cases of imported malaria confirmed and recorded by the reference laboratory of Finland (population 5.4 million) from 2003 to 2011, and these were compared with those reported to the National Infectious Disease Register (NIDR). Background information was gathered by detailed questionnaires sent to the clinicians upon diagnosis; missing data were enquired by telephone of clinician or patient. Special attention was paid to compliance with chemoprophylaxis: self-reported use of anti-malarials was rechecked for all cases of P. falciparum.

RESULTS

A total of 265 malaria cases (average annual incidence rate 0.5/100,000 population) had been recorded by the reference laboratory, all of them also reported to NIDR: 54% were born in malaria-endemic countries; 86% were currently living in non-endemic regions. Malaria was mainly (81%) contracted in sub-Saharan Africa. Plasmodium falciparum proved to be the most common species (72%). Immigrants constituted the largest group of travellers (44%). Pre-travel advice was received by 20% of those born in endemic regions and 81% of those from non-endemic regions. Of those with P. falciparum, 4% reported regular use of appropriate chemoprophylaxis (mefloquine or atovaquone/proguanil or doxycycline for regions with chloroquine-resistant and atovaquone/proguanil or doxycycline for regions with mefloquine-resistant P. falciparum); after individual rechecking, however, it was found that none of them had been fully compliant.

CONCLUSIONS

Information on compliance with chemoprophylactic regimen cannot be relied on, and it should be rechecked if malaria is suspected. The results of the present study suggest that mefloquine, atovaquone/proguanil and doxycycline are effective as chemoprophylaxis against P. falciparum malaria, when taken conscientiously.

Serodiagnosis of primary infections with human parvovirus 4, Finland

To determine the prevalence of parvovirus 4 infection and its clinical and sociodemographic correlations in Finland, we used virus-like particle-based serodiagnostic procedures (immunoglobulin [Ig] G, IgM, and IgG avidity) and PCR. We found 2 persons with parvovirus 4 primary infection who had mild or asymptomatic clinical features among hepatitis C virus-infected injection drug users.

HIV outbreak among injecting drug users in the Helsinki region: social and geographical pockets

BACKGROUND

Incidence of newly diagnosed HIV infections among injecting drug users (IDUs) in Helsinki rose from 0 per 100,000 inhabitants in 1997 to 2.9 in 1998 and to 11.1 in 1999. Thereafter incidence declined to 2.1 in 2003.

METHODS

Data were collected from interviews with HIV-positive IDUs who attended the University Hospital in Helsinki from 1998 until 2003. We studied the sociodemographic profile and spatial distribution of IDUs who were diagnosed in the beginning of the outbreak and those diagnosed later. The indicator for the spatial differentiation within the metropolitan area is % employed males aged 25-64.

RESULTS

The outbreak occurred among a marginalized population of IDUs characterized by a long history of injecting drug use (10.7 years), mean age 32 years, homelessness (66.3%), history of imprisonment (74.7%) and psychiatric hospital care (40.6%). Compared with 98 early cases diagnosed during the first 2 years until 2000, 47 recent cases diagnosed after 2001 were 4 years older, and as marginalized. Except for the city centre, both early and recent cases had been living or using drugs in the same deprived neighbourhoods with the highest unemployment rates. Up to 40% of cases in the two big geographical clusters did not have contact with the city centre, where the needle exchange services were available.

CONCLUSIONS

The Finnish HIV outbreak is restricted socially to a very marginalized IDU population, and spatially to local pockets of poverty. In low prevalence countries, prevention programs should be targeted early at high-risk areas and populations.

Development of a scintiplate assay for recombinant human alpha(2B)-adrenergic receptor

A high-throughput solid-phase platform for ligand-binding assays using microtiter plates (Scintiplates) has been developed using the scintillation proximity assay principle. The system has been developed using human alpha(2B)-adrenergic receptor (alpha(2B)-AR) expressed from Semliki Forest virus vectors in CHO cells. Alpha(2B)-AR bind natural (adrenaline and noradrenaline) and synthetic ligands with different affinities to mediate a variety of physiological and pharmacological responses. Antagonist radioligands were used for the binding experiments, and the values obtained for the binding constants with the Scintiplate system are in good agreement with those obtained by the traditional filter-binding assay system. The Scintiplate assay offers the advantages of a high-throughput format over the filter-binding assay and is amenable for screening many compounds rapidly for generation of leads.

Use of obstetric forceps in Finland today--experience at Vaasa Central Hospital 1984-1998

BACKGROUND

Forceps delivery has become rare in Finland since the introduction of the vacuum extractor. Our aim was to survey the number of forceps deliveries in Finland and analyze our own material of 130 forceps deliveries during a 15-year period between 1984 and 1998. During this period there were 17,887 deliveries at Vaasa Central Hospital.

METHODS

A retrospective study of 130 forceps deliveries and 11 trial forceps cases, which subsequently resulted in a cesarean section.

RESULTS

There was no maternal or neonatal mortality. In 39 cases a cesarean section could be avoided by use of forceps after a failed vacuum extraction. Only in one case was maternal morbidity regarded as serious. There was no serious neonatal morbidity. Anal sphincter ruptures occurred in three cases (2.3%). All the women in the trial forceps group were nulliparous, in 73% of these the fetus was in a persistent occipito-posterior position. Failed vacuum extraction and trial forceps did not significantly influence neonatal outcome.

CONCLUSIONS

Forceps delivery appears to be a safe alternative in our setting.

Scintillating microtitration plates as platform for determination of [3H]estradiol binding constants for hER-HBD

A novel approach to direct determination of ligand binding constants for the human estrogen receptor hormone binding domain was developed. Recombinantly produced human receptor in yeast extracts was attached to scintillating microtitration plates. Radioligand binding to receptors was determined in a multi-detector scintillation counter designed for the microtitration plate format. The method was employed in equilibrium binding experiments, in binding competition tests and in determination of kinetic rate constants. The results obtained show that the methodology is valid in comparison to previously published data regarding hormone binding characteristics of estrogen receptors. Furthermore, the methodology offers several advantages over previous binding assays because the scintillating microtitration plates constitute both the binding reaction vial and the scintillant for the detection of bound radioactivity.