Increase of syphilis in Finland related to the Russian epidemic

A u début des années 1990, seulement 30 à 40 nouveaux cas confirmés de syphilis étaient déclarés chaque année en Finlande. Les patients atteints de syphilis étaient généralement des hommes hétérosexuels ayant été infectés à l’étranger. Depuis 1993, l’incidence de la syphilis a augmenté (voir figure, page suivante). En 1995, au total, 118 nouveaux cas ont été diagnostiqués, ce qui représente pratiquement le double du nombre de cas diagnostiqués en 1994 (63 cas). Trente sept pour cent de l’ensemble des patients avec une syphilis diagnostiquée en 1995 étaient des femmes dont 77% avaient acquis leur infection en Finlande. Soixante cinq pour cent des hommes diagnostiqués en 1995 avaient été infectés à l’étranger, principalement en Russie (51%) (1). En 1995, la plupart des cas résidaient dans le sud de la Finlande ou dans le sud-est près de la frontière russe. Un foyer de 30 patients a été découvert dans la partie centrale de la Finlande, dans la ville de Tempere. Trois hommes ayant contracté ➤ Increase of syphilis in Finland related to the Russian epidemic

Ce rapport montre la nécessité d'une surveillance régulière de la syphilis afin de cibler les services cliniques et de prévention pour les personnes les plus exposées au risque de transmission.s ® Travel to St Petersburg and to neighbouring areas for business and for pleasure has increased remarkably since the Soviet Union collapsed.In 1995, the incidence of syphilis in Russia was 86 times higher (172/100 000) than in Finland (2/100 000) and is increasing (twofold during 1994-95).In 1995, 255 000 cases of syphilis were reported in the Russian Federation.In St Petersburg the incidence of syphilis (318/100 000; 15 000 reported cases) is among the highest in Russian administrative territories (2).
Women have been screened for syphilis infection in early pregnancy in Finland for 50 years.No congenital cases of syphilis have been reported since 1981.From 1991 to 1995, serum specimens from 332 400 pregnant women were tested.Positive results with non-treponemal antigens (RPR) were detected in specimens from 839 women; 73 of these specimens were also positive in the treponemal antigen test (treponemal haemagglutination).Old, treated syphilis infection was the cause of positivity in 54 cases.Undiagnosed, early (primary/secondary) syphilis was detected in the remaining 19 patients.In 1995, six early cases of syphilis were identified among pregnant women.Two women were Finnish, three Russian, and one was from Thailand (3).
This report stresses the need for timely surveillance of syphilis in order to target clinical and prevention services to people exposed to the risk of transmission.s L es infections à Escherichia coli O157 se manifestent par des diarrhées bénignes, des colites hémorragiques sévères et par le syndrome hémolytique urémique (SHU).Entre 2% et 21% des cas observés développent un SHU avec un taux de létalité de 3 à 7% (1) E scherichia coli O157 infections present in different ways, including mild diarrhoea, severe haemorrhagic colitis, and the haemolytic uraemic syndrome (HUS).Between 2% and 21% of cases have been observed to develop HUS, whose case fatality rate is 3% to 7% (1).E. coli may be isolated from faeces.The diagnosis of HUS is clinical, and may be corroborated by isolation of the organism or the identification of antibodies to E. coli O157 lipopolysaccharide in the blood.Several outbreaks of E. coli O157 infection have occurred in Great Britain, Canada, and the United States in recent years.
The Swedish Institute for Infectious Disease Control (Smittskyddsinstitutet -SMI) received no more than three reports of enterohaemorrhagic E. coli O157 infections (EHEC) each year from 1988 to 1994.About half of these were due to E. coli O157.In July 1995, two cases (two siblings) with diarrhoea caused by E. coli O157 were observed and reported in the Journal of the Swedish Medical Reports were received from most counties and it was assumed that the outbreak was caused by a common source with a nationwide distribution.The SMI began a case control study.The case definition included clinical features (diarrhoea or HUS) and laboratory confirmed infection with E. coli O157 in stool specimens.If several members of a household were affected, only the first case (index case) was included in the study.Two controls were matched to each case by sex, age, and region from the Swedish central population register.A detailed questionnaire was administered over the telephone.It included demographic information and over 150 questions about the consumption of food items.By 1 December, the case control study had not implicated any single food and a new questionnaire, including questions about food handling, was therefore introduced.

Outbreak of Escherichia coli O157 in Sweden
Over 200 food samples from refrigerators and freezers in patients' homes and from stores where food had been bought were investigated for the presence of E. coli O157, with negative results.In parallel, the SMI developed and established a PCR for detailed sub-typing of E. coli O157.At the beginning of the outbreak, the subtyping was restricted to E. coli O157 and showed that different subtypes of E. coli O157 were involved.To clarify the distinction between strains, a new classification was introduced and is currently being evaluated.
The SMI, the National Food Administration, and the consultants in communicable disease control (CCDCs) took the opportunity of the great public interest during this first EHEC outbreak in Sweden to stress the importance of good hygienic standards in the kitchen to prevent infection with EHEC.In February 1996 the SMI, the National Board of Health, and the National Food Administration began a surveillance study of the presence of E. coli O157 in imported and Swedish meat in February.Some 1600 samples of beef will be investigated to estimate the frequency of E. coli O157.
Il n'a pas été réalisé d'enquête sur un groupe contrôle provenant soit de l'institu-tion, soit de la communauté, ni d'étude analytique pour déterminer si la nourriture pouvait être le véhicule de l'infection.L'investigation de cette épidémie souligne le risque d'une transmission secondaire après une infection alimentaire si l'hygiène est négligée.Bien que la shigellose soit habituellement une maladie de gravité limitée, quand elle apparaît dans une institution prenant en charge de très jeunes enfants ou des personnes ne pouvant assurer leur propre hygiène, une attention spéciale doit porter à la fois sur les mesures d'hygiène et sur l'administration d'un traitement antimicrobien approprié aux patients.Il est probable que la résistance de l'organisme aux antibiotiques usuels et la non-exclusion des personnes convalescentes de l'institution ont joué un rôle important dans l'extension de l'infection (2) T he introduction of shigella into a child care centre carries a high risk of secondary spread from person to person within the centre (1).We report an outbreak of shigellosis in early 1995 that affected 99 children, 17 of their relations, and seven workers in a day care institution for children under 10 years of age.The health authority closed the institution for five days to control the outbreak and all the families at risk were contacted in order to give an appropriate antimicrobial drug to all those affected.
The outbreak occurred in late February and early March.Those who became ill suffered diarrhoea with blood, mucus, and pus and high fever, cramps, and malaise.Three patients were admitted to hospital.Shigella sonnei was isolated from the stools of nine cases tested at random and the three children admitted to hospital.The strain isolated in each case was resistant to tetracycline and co-trimoxazole.
The outbreak occurred in two waves (figure).In the first wave 65 cases were reported in five days.The attack rate differed with age: two out of 48 kindergarten children (aged less than 3 years) became ill (4.1%) and 65 out of 222 older children and adults (28.4%).It seemed likely that a common source of infection was responsible (figure).The children and adults had eaten lettuce and home made mayonnaise prepared with raw eggs, but no leftover food was available for testing.
In the second wave of the outbreak 41 cases occurred in a pattern compatible with spread through faecal oral transmission from convalescent cases to susceptible people in the institution.
It appeared that co-trimoxazole, with which cases had been treated in the early phase, had not prevented the second wave of infection.At this point the institution was closed for five days during which 82 cases were given antibiotic treatment, mostly amoxycillin to which the organism was sensitive.Subsequently a random sample of 43 patients submitted faecal specimens, all of which were negative.In addition to these two measures, asymptomatic carriers were excluded among foodhandlers.
No control groups from the institution or the community were investigated and no analytical study was conducted to investigate the possibility that the first wave of cases was associated with a food vehicle.The investigation of this outbreak highlighted the risk of secondary transmission after a foodborne infection if hygiene is neglected.Although shigellosis is usually a self limiting disease, when it occurs in an institution for very young children or others unable to manage their own personal hygiene, special care should be taken both with hygiene measures and the administration of antimicrobial drugs to patients.It is likely that the organism's resistance to common antibiotics and the initial failure to exclude convalescent cases from the institution contributed to the spread of infection (2).s
Le texte complet des recommandations comprenant la liste de tous les membres du groupe de travail est publié dans le European Respiratory Journal (3).

Introduction
The most readily accessible and informative indicator of morbidity caused by tuberculosis is the incidence of disease.In Europe, differences between countries in case definitions, reporting systems, and information collection make comparison difficult (1,2) and hamper analysis of time trends, identification of common population groups in whom the incidence is high, and the international coordination of efforts to control tuberculosis in Europe.This paper summarises recommendations for uniform reporting on tuberculosis cases made by a working group set up in 1994 following a meeting on tuberculosis control in low prevalence countries.The meeting had been organised jointly by the World Health Organization (WHO), the European Region of the International Union Against Tuberculosis and Lung Disease (IUATLD), and the Royal Netherlands Tuberculosis Association (KNCV).The working group consisted of representatives of governmental and non-governmental organisations of 37 countries of the WHO European Region, including all 15 countries of the European Union.The complete report of the recommendations with the list of all members of the working group is published in the European Respiratory Journal (3).

Case definition
For countries where level II laboratories (capable of identification of Mycobacterium tuberculosis complex [4]) are routinely available, a "definite" case of tuberculosis is a case with culture confirmed disease due to M. tuberculosis complex.In countries where routine culturing of specimens cannot be afforded or expected, a patient with sputum smear examinations positive for acid-fast bacilli is also considered to be a definite case.
Reporting is also required for "other than definite" cases which meet both of the following conditions: 1) a clinician's judgement that the patient's clinical and/or radiological signs and/or symptoms are compatible with tuberculosis, and 2) a clinician's decision to treat the patient with a full course of antituberculosis treatment.
Definite and other than definite cases should be reported separately to enable definite cases and their proportion among all cases to be internationally compared.

Data collection, reporting and analysis
Most countries in Europe have legal provisions for mandatory reporting by physicians.Nevertheless the legal requirement to report cannot usually be enforced.Since there are fewer level II laboratories (4) than there are physicians potentially seeing cases, the working group recommends that national health authorities make reporting of tuberculosis mandatory for both physicians and laboratories.Laboratories should be asked to report each pathogenic isolate of M. tuberculosis complex.Local/regional level: All patients started on anti-tuberculosis medication should be notified by their physician to the local health authorities within one week.For this initial report, the full name, date of birth and sex of the patient, presumptive diagnosis, date of starting treatment, and name and address of the reporting physician is enough to ensure that contact tracing can start in collaboration with the physician.These preliminary reports could be sent, say, weekly, to the national health authorities to allow the early detection of changes in time trends.
Local health authorities should seek further information from reporting physicians by means of an extended reporting form.This information should be returned to the local health authority within a maximum of three months after a suspected case is reported, providing sufficient time to classify definitively a suspect as a notifiable case of tuberculosis.Laboratories that identify M. tuberculosis complex should provide information about the bacteriological findings together with the name and address of the physician and the full name, date of birth, and sex of the patient to enable further information to be obtained from the physicians about cases not previously reported.® ® le nom et l'adresse du médecin, ainsi que les nom, prénom, date de naissance et sexe du patient ; cela permettra de retrouver, avec le médecin concerné, les informations sur un cas qui n'aurait pas été déclaré .
Age, sexe et pays de naissance -La date de naissance et le sexe sont des variables qui devraient être connues pour chaque patient.Vue l'importance croissante de la tuberculose chez les immigrés et autres étrangers dans les pays européens, le "Task Force on Tuberculosis Control and International Migration" (5) a identifié le pays de naissance comme la variable supplémentaire à recueillir en routine.Le pays de naissance n'est pas toujours la variable la plus pertinente et certains pays peuvent aussi recueillir des données sur l'origine ethnique, la nationalité du patient ou celle des parents.
Localisation de la maladie -Elle devrait toujours être indiquée.Des patients peuvent présenter plusieurs localisations.Dans ce cas, au moins deux localisations, une ® Depending on the resources available, local health authorities have the responsibility to collect information, definitively classify cases, link information from different sources (laboratories, physicians), follow up cases not previously reported by one of the sources, complete missing information, and eliminate duplicate reporting.They should send individual (non-aggregate) information to the national authorities, with or without name or other identifier depending on the country' s legal requirements, continually or at least quarterly.In the absence of sufficient local resources, named (or suitably coded) data would have to be sent to the national health authorities .
National level: Public health authorities should regularly analyse, interpret, and publish collected surveillance data.Data from the local/regional level should be aggregated at least quarterly for the publication of preliminary national statistics.It will usually be sufficient for final summary reports to be produced annually.Ideally, analysis should be carried out according to the year when treatment began, provided the calendar year is closed at the end of the first quarter in the following year, to allow sufficient time for the case to be verified.

Essential variables
Date of starting treatment -To obtain accurate estimates of incidence, the date of onset of disease or the date of diagnosis should be known, but this may often be difficult to fix in time.The date of starting treatment constitutes a reasonable proxy and the working group recommends that it should be recorded in all cases.For pulmonary tuberculosis, the date when treatment starts will usually coincide with the date when a positive sputum smear result is obtained from the laboratory or, in sputum smear negative cases, when the clinician has gathered enough clinical and/or radiological evidence for the diagnosis to justify starting treatment.If the date of starting treatment is unavailable, the date when the case was notified may be substituted.For cases that never received treatment -for example, postmortem diagnoses -the date of diagnosis should be substituted.
Place of residence -Recording the place of residence of a tuberculosis patient is essential for public health action.After appropriate aggregation, the place of residence also provides information about differences in disease frequency in different parts of the country.The place of residence should be where the patient was living at the time treatment began.In cases of homeless people, migrants, and detainees, the place of residence within the country during the previous three months might be used.For European comparison, aggregation by country will usually suffice.
Age, sex, and country of birth -Date of birth and sex are variables that should be known for each patient.In view of the increasing importance of tuberculosis among immigrants and other foreigners in European countries, the Task Force on Tuberculosis Control and International Migration (5) identified country of birth as the additional variable that should be collected routinely.Country of birth may not always be the most relevant variable and some countries may also collect data on ethnicity, citizenship, or citizenship of parents.
Site of disease -It should always be recorded.Patients may have multiple sites of disease and it is therefore recommended that at least two sites, a major and a minor site, when applicable, should be recorded.The use of the following classification will enable consistent data to be collated and analysed within and between countries: • Pulmonary tuberculosis is defined as tuberculosis of the lung parenchyma and the tracheobronchial tree only.It is proposed that pulmonary tuberculosis, if present, should always be listed as the major site whatever other site may A l'échelon européen, les cas devraient être classés en trois groupes : tuberculose uniquement pulmonaire, pulmonaire et extrapulmonaire, et uniquement extrapulmonaire.

Conclusion
Ce document représente un consensus sur des recommandations techniques pour permettre aux gouvernements européens de structurer et de standardiser leur ® additionally be affected.Extrapulmonary tuberculosis is then defined as tuberculosis affecting any site other than pulmonary.
• Pleural tuberculosis is defined as extrapulmonary tuberculosis and is tuberculous pleurisy only, with or without effusion.Bacteriological status -Information about the bacteriological status of cases must always be included.The result of culture (negative or positive for M. tuberculosis complex, not done, or pending) and the source specimen must be recorded by the physician and the laboratory.Whenever possible, further differentiation of isolates into M. tuberculosis, M. bovis, or M. africanum should also be reported.Similarly, the result of direct microscopic examination (negative or positive for acid-fast bacilli, or not done) and the source specimen providing a positive result must be reported.Cases of pulmonary tuberculosis should be divided into smear positive and smear negative cases based on direct microscopic smear examination of spontaneously produced or induced sputum.Cases positive on microscopy of material obtained from bronchoalveolar or gastric lavage only should not be considered to be sputum smear positive.Histological examination with evidence of acid-fast bacilli should be considered as positive microscopy.
Recurrent or new disease -It must be made clear for epidemiological purposes whether or not a notified case has had tuberculosis before.In reporting recurrent cases, care must be taken to ensure that chronic cases and patients that intermittently abscond and return are not repeatedly notified.Information on the existence and date of prior diagnosis of tuberculosis and on previous antituberculous chemotherapy will allow recurrent cases to be classified into relapse (previous treatment considered as adequate) and recurrence with or without previous chemotherapy.
Other variables -Additional variables such as tuberculin skin test results, results of chest radiographs, patient's citizenship, subdivision of foreigners into migrant workers, refugees/asylum seekers, and other foreigners, duration of residence within the country for patients born elsewhere, and cases not diagnosed until after death, may be collected for individual, local, or national purposes.However, completeness of case reporting is likely to be better if the information requested is kept to a minimum.Specific surveys may be used to answer more complex questions of special interest in tuberculosis control.

Conclusion
This document represents a consensus of technical recommendations to European governments on how to structure their tuberculosis surveillance systems with a view to standardisation that would allow international comparisons.The interpretation of surveillance figures must include an appreciation of the quality of data from individual countries.Most countries collect all the information considered essential to allow uniform reporting of tuberculosis cases in Europe.Most systems would thus need only minor modifications.The members of the working group, WHO, ® ® système de surveillance pour rendre possibles des comparaisons internationales.L'interprétation de données de surveillance devrait comporter une appréciation de la qualité des données par chaque pays.La majorité des pays européens collecte déjà toutes les informations considérées comme indispensables pour permettre une déclaration uniforme des cas de tuberculose à l'échelon européen.La plupart des systèmes ne nécessiteront donc que des modifications mineures.Les membres du groupe de travail, l'OMS et la région Europe de l'UICTMR considèrent qu'il est essentiel d'obtenir régulièrement les données de surveillance de la tuberculose fournies par les gouvernements nationaux, de faire des analyses comparatives internationales de ces données, et de les distribuer aux états participants.L'OMS a officiellement invité tous les ministères de la santé de sa région Europe à adopter ces recommandations.Un projet d'un an pour la surveillance de la tuberculose en Europe, basé sur ces recommandations, a été développé par le Centre Européen pour la Surveillance Epidémiologique du SIDA en collaboration avec le KNCV.Il est financé par la DG V de la Commission Européenne et démarre en 1996.s ® and the European Region of the IUATLD consider it essential to obtain regular surveillance data on tuberculosis from national governments, to make international comparative analyses of these data, and to distribute them to participating member states.WHO has officially invited all ministries of health of its European region to adopt the recommendations.A one year project for tuberculosis surveillance in Europe, developed by the European Centre for the Epidemiological Monitoring of AIDS in collaboration with the KNCV and funded by the Directorate General V of the European Commission, will start in 1996 based on these recommendations.s s A Suspiro 1 , L Menezes 2 1 Public Health Doctor, Health Authority 2 Public Health Doctor From: Saùde em nùmeros, 1996; (11) 1: 5-7

RAPPORT
Figure

de EHEC déclarés par semaine de survenue -Suède (Juillet 1995-Février 1996) Cases of reported EHEC by week of onset -Sweden (July 1995-February 1996)
The results of the case control study are not yet complete, as not all the laboratory analyses are available.As a result of this outbreak, most of the microbiological laboratories now look routinely for EHEC in faecal specimens from patients with bloody diarrhoea.Because of the possibility of further outbreaks, infections with EHEC became notifiable in Sweden in January 1996.

•
Lymphatic tuberculosis includes tuberculosis involving the lymphatic system.Because of the intrathoracic manifestations of tuberculosis in children and in patients with HIV infection, lymphatic tuberculosis is preferably further differentiated into intrathoracic and extrathoracic lymphatic tuberculosis.Tuberculosis of the genitourinary system includes tuberculosis of kidney, ureter, bladder, and male and female genital tracts.•Peritoneal/digestivetract tuberculosis includes tuberculosis of the peritoneum with or without ascites and tuberculosis of the digestive tract.•Other extrapulmonary sites, including laryngeal tuberculosis.•Disseminated tuberculosis includes miliary tuberculosis, tuberculosis in which M. tuberculosis complex has been isolated from blood, and tuberculosis of more than two organ systems.If one of the affected sites is the lung parenchyma, the case should be classified as having both pulmonary and disseminated tuberculosis.Miliary tuberculosis is classified as both pulmonary and disseminated.
For European comparison, cases should be classified into three groups: pulmonary tuberculosis only, pulmonary and extrapulmonary, and extrapulmonary tuberculosis only.