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We evaluated the Finnish Hospital Infection Program (SIRO) conducting incidence surveillance for prosthetic joint infection (PJI) from 1999 to 2004. We estimated its sensitivity using capture-recapture methods and assessed the disease burden of PJIs after hip (THA) and knee (TKA) arthroplasties (N = 13 482). The following three data sources were used: SIRO, the Finnish Arthroplasty Register (FAR), and the Finnish Patient Insurance Center (FPIC), which were cross-matched, and 129 individual PJIs were identified. After adjusting for the positive predictive value of SIRO (91%) a log-linear model including an interaction term between FAR and FPIC provided an estimated PJI rate of 1.6% [95% confidence interval (CI): 1.2-2.4] for THA and 1.3% (1.1-1.6) for TKA. Sensitivity for SIRO varied from 36% to 57%. The annual disease burden was 2.1 PJIs per 100 000 population after THA and 1.5 after TKA. The true disease burden of PJIs may be heavier than the rates from national sentinel surveillance systems usually suggest. [ABSTRACT FROM AUTHOR]

BACKGROUND: We estimated the burden of health care-associated infections (HAIs) occurring in Finnish adult acute care hospitals using national hospitalization data and estimates of HAI based on a recent national prevalence survey. METHODS: A total of 7531 non-HAI patients and 703 HAI patients (8.5%) identified in the prevalence survey were included in the study. Using the patients' national identity numbers and the prevalence survey date, we obtained data on hospitalizations, including discharge diagnoses from the National Hospital Discharge Registry (NHDR), and the dates and causes of death from the National Population Information System. We converted the prevalence of HAI into incidence using the Rhame-Sudderth formula, assessed the 28-day case fatality of the HAI patients, and then extrapolated the annual estimates of HAI burden from the total number of hospitalizations in adult acute care hospitals in 2005 (n = 804,456). We also assessed the sensitivity of the NHDR diagnoses in identifying HAIs. RESULTS: The estimated incidence of HAIs was 5.7% (95% confidence interval = 5.0% to 6.5%), and the 28-day case fatality was 9.8%. Thus, >8500 hospitalizations per million population annually would result in at least 1 HAI and approximately 270 HAI-associated deaths within 28 days. The sensitivity of the NHDR diagnoses was 34% (range by infection type, 0% to 67%). CONCLUSION: Our disease burden estimates can be used in health care planning and resource allocation. The NHDR was not a reliable source for case finding of HAIs. [ABSTRACT FROM AUTHOR]

The article discusses findings of a questionnaire study on the joint symptoms after the outbreak of gastroenteritis in Nokia, Finland. Topics include Campylobacter being the most common pathogen found in patient's faecal culture, occurrence of reactive arthritis and symptoms like pain in the joint movement, swelling of the joints and redness in the joints.

This article addresses the need to grasp the actual processing of health ethical issues in ethics organisations by analysing the work of the Finnish National Advisory Board on Social Welfare and Health Care Ethics (ETENE). ETENE's ethics is approached ethigraphically: the advisory board enacts ethics in its social life, through its own norms and values. It is asked how this internal ethics is performed in the board practice and how ethical debate eventually becomes bounded in this practice. Based on the analysis of the board members' textual reflections and on-site observations of board meetings, ETENE's ethics appears as a tandem of a particular discussion culture and multi-perspectivity: mutual recognition and respect among board members are nurtured in the meetings, and a tactful mode of reflection is established throughout all terms of office. This shared discussion culture enables ETENE's forte-weighing multiple perspectives-by preventing asymmetries and avoiding merely technical decision-making procedures. Consequently, ETENE's ethics is not threatened by being externally bounded and formalised but is at risk of watering down endogenously, through the notable tactfulness of its discussion mode, which threatens to attenuate both substantial debate and the social shaping of board members' values in the discussion., (© 2023 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for the Sociology of Health & Illness.)

Introduction: Health care professionals working in primary and specialized care typically search for medical information from Internet sources. In Finland, Physician's Databases are online portals aimed at professionals seeking medical information. As dosage errors may occur when prescribing medication to children, professionals' need for reliable medical information has increased in public health care centers and hospitals. Influenza continues to be a public health threat, with young children at risk of developing severe illness and easily transmitting the virus. Oseltamivir is used to treat children with influenza. The objective of this study was to compare searches for children's oseltamivir and influenza diagnoses in primary and specialized care, and to determine if the searches could aid detection of influenza outbreaks., Methods: We compared searches in Physician's Databases for children's oral suspension of oseltamivir (6 mg/mL) for influenza diagnoses of children under 7 years and laboratory findings of influenza A and B from the National Infectious Disease Register. Searches and diagnoses were assessed in primary and specialized care across Finland by season from 2012-2016. The Moving Epidemic Method (MEM) calculated seasonal starts and ends, and paired differences in the mean compared two indicators. Correlation was tested to compare seasons., Results: We found that searches and diagnoses in primary and specialized care showed visually similar patterns annually. The MEM-calculated starting weeks in searches appeared mainly in the same week. Oseltamivir searches in primary care preceded diagnoses by -1.0 weeks (95% CI: -3.0, -0.3; p = 0.132) with very high correlation (τ = 0.913). Specialized care oseltamivir searches and diagnoses correlated moderately (τ = 0.667)., Conclusion: Health care professionals' searches for children's oseltamivir in online databases linked with the registers of children's influenza diagnoses in primary and specialized care. Therefore, database searches should be considered as supplementary information in disease surveillance when detecting influenza epidemics., Competing Interests: MK has held various trustee positions in the Finnish Medical Society Duodecim since the late 1990s. OH has held various trustee positions in the Finnish Medical Society Duodecim and Duodecim Medical Publications Ltd since 2009 and is a partner at iHealth Finland Ltd. The other authors have no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

In the present study, we examine socio-cultural and practical aspects of human papillomavirus vaccination (HPVV) through a multi-sited study of framings. We ask how HPVV is framed in the daily lives of vaccination-aged Finnish girls and in school nurses' everyday work. We then mirror these framings against both each other and Finland's official vaccination campaign. Based on analysis of interviews with 24 nurses and 12 girls and the campaign materials, we argue first that the campaign frames vaccination as an individual, knowledge-based decision reflecting the informed consent principle. Second, however, the vaccination is framed in the everyday lives of eligible girls through gendered social ties and as a gendered and cohort-specific event pivoting around the needle prick. Third, HPVV is not primarily framed in the school nurses' work as preparing the girls for the vaccination decision by sharing official information but through trust-based social relationships with the girls and their parents. We conclude that, as the vaccination is not an issue of individually reflected and knowledge-based decision-making for the two interviewed key groups, the official Finnish HPVV campaign and the undergirding informed consent principle drift into problems in their practical implementation., (© 2021 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL (SHIL).)

Objectives: Weekly monitoring of European all-cause excess mortality, the EuroMOMO network, observed high excess mortality during the influenza B/Yamagata dominated 2017/18 winter season, especially among elderly. We describe all-cause excess and influenza-attributable mortality during the season 2017/18 in Europe., Methods: Based on weekly reporting of mortality from 24 European countries or sub-national regions, representing 60% of the European population excluding the Russian and Turkish parts of Europe, we estimated age stratified all-cause excess morality using the EuroMOMO model. In addition, age stratified all-cause influenza-attributable mortality was estimated using the FluMOMO algorithm, incorporating influenza activity based on clinical and virological surveillance data, and adjusting for extreme temperatures., Results: Excess mortality was mainly attributable to influenza activity from December 2017 to April 2018, but also due to exceptionally low temperatures in February-March 2018. The pattern and extent of mortality excess was similar to the previous A(H3N2) dominated seasons, 2014/15 and 2016/17. The 2017/18 overall all-cause influenza-attributable mortality was estimated to be 25.4 (95%CI 25.0-25.8) per 100,000 population; 118.2 (116.4-119.9) for persons aged 65. Extending to the European population this translates into over-all 152,000 deaths., Conclusions: The high mortality among elderly was unexpected in an influenza B dominated season, which commonly are considered to cause mild illness, mainly among children. Even though A(H3N2) also circulated in the 2017/18 season and may have contributed to the excess mortality among the elderly, the common perception of influenza B only having a modest impact on excess mortality in the older population may need to be reconsidered., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Healthcare professionals (HCPs) search medical information during their clinical work using Internet sources. In Finland, Physician's Databases (PD) serve as an Internet medical portal aimed at HCPs. Influenza epidemics appear seasonal outbreaks causing public health concern. Oseltamivir can be used to treat influenza. Little is known about HCPs' queries on oseltamivir and influenza from dedicated online medical portals and whether queries could be used as an additional source of information for disease surveillance when detecting influenza epidemics., Methods: We compared HCPs' queries on oseltamivir and influenza from PD to influenza diagnoses from the primary healthcare register in Finland 2011-2016. The Moving Epidemic Method (MEM) calculated the starts of influenza epidemics. Laboratory reports of influenza A and influenza B were assessed. Paired differences compared queries, diagnoses, and laboratory reports by using starting weeks. Kendall's correlation test assessed the season-to-season similarity., Results: We found that PD and the primary healthcare register showed visually similar patterns annually. Paired differences in the mean showed that influenza epidemics based on queries on oseltamivir started earlier than epidemics based on diagnoses by -0.80 weeks (95% CI: -1.0, 0.0) with high correlation (τ = 0.943). Queries on influenza preceded queries on oseltamivir by -0.80 weeks (95% CI: -1.2, 0.0) and diagnoses by -1.60 weeks (95% CI: -1.8, -1.0)., Conclusions: HCPs' queries on oseltamivir and influenza from Internet medical databases correlated with register diagnoses of influenza. Therefore, they should be considered as a supplementary source of information for disease surveillance when detecting influenza epidemics., (© 2019 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

This article focuses on two different ways of framing and taming the uncertainties of the human papillomavirus (HPV) vaccine in the context of the Finnish welfare state: the bio-medical rationale of population-level cancer reduction based on epidemiological assessments, and the meaning formation of Finnish vaccination-aged girls. Epidemiologists run analyses estimating the cost-effectiveness and public health benefit of vaccinations, while the adolescent girls face the burdensome choice of whether to undergo vaccination. The processes of framing the complexities and actively taming them are analysed utilising a cultural-sociological framework. Firstly, the taming work of the epidemiologists is examined by focusing on the creation of the vaccination campaign. The aetiological complexities between some HPV types and cervical cancer are tamed into a clear campaign message of vaccination as a scientifically proven protection against deadly cancer. Secondly, the girls' own ways of framing the complexities of the HPV vaccine and taming the decision whether to undergo vaccination or not are analysed based on their comments in an Internet discussion forum. Finally, the framings and tamings of both sites are discussed together, and some interesting continuities and disjunctions between the two are revealed., (© 2019 The Author. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL.)

Background: The ten-valent pneumococcal conjugate vaccine (PCV10) was introduced into the Finnish National Vaccination Programme (NVP) in September 2010. The impact of PCV10 vaccination against invasive pneumococcal disease (IPD) in vaccine-eligible children has been high. We evaluated the long-term impact of PCV10 vaccination against IPD in vaccine-eligible and older, unvaccinated children six years after PCV10 introduction with a special focus on cross-protection against PCV10-related serotypes (serotypes in the same serogroups as the PCV10 types)., Methods: We used data on IPD from the national, population-based surveillance. A target cohort of vaccine-eligible children (born June 2010 or later) was followed from 3 months of age until the end of 2016. For the indirect effect, another cohort of older PCV10-ineligible children was followed from 2012 through 2016. IPD rates were compared with those of season- and age-matched reference cohorts before NVP introduction., Results: Among vaccine-eligible children, the incidence of all IPD decreased by 79% (95% CI 74-83%). There was a statistically significant reduction in the incidence of 6A IPD, but for 19A, the reduction was non-significant and the incidence of 19A increased towards the end of the study period in the older vaccine-eligible children. The increase in non-PCV10 related serotypes was non-significant. In the unvaccinated older children, the incidence of all IPD decreased by 33% (95% CI 8-52%) compared to the reference cohort, and there was no impact on serotype 6A or 19A IPD., Conclusion: Overall, the impact of PCV10 vaccination on IPD was high in vaccine-eligible children, with a major reduction in vaccine-type disease, and without notable replacement by other serotype groups. Our data suggest that PCV10 results in long-lasting direct cross-protection against 6A IPD. For 19A, no net reduction was observed six years after NVP introduction in the vaccine-eligible cohort. The indirect impact on IPD in unvaccinated children sustained., (Copyright © 2018. Published by Elsevier Ltd.)

Lyme borreliosis (LB) is caused by Borrelia burgdorferi sensu lato (Bb-sl) and is the most common vector-borne disease in Europe. The objectives of this study were to determine the Bb-sl seroprevalence among the general Finnish adult population and to identify risk factors associated with Bb-sl-seropositive status. Two thousand sera from a nationwide health survey from 2011 were tested by whole-cell sonicate IgG ELISA, C6 peptide ELISA, and recomBead IgG 2.0 and test results were linked to a general health questionnaire. A multivariable logistic regression model was used to identify risk factors. The median age of the study population was 56 years (range 29-97) and the Bb-sl weighted seroprevalence was 3.9% (95% confidence interval (CI) 3.03-5.08). The weighted seroprevalence was significantly higher among males than females (adjusted odds ratio 1.91, 95%CI 1.21-3.04). The seroprevalence was highest in Southern, Central, and Eastern regions. The first Bb-sl seroprevalence study in Finland showed a seroprevalence of 3.9% (regional range 0.87%-6.12%). The results of this study can be used, together with previous data on LB incidence and spatial tick distribution, to target public health communication about preventive measures., (Copyright © 2017 Elsevier GmbH. All rights reserved.)

Background: People using the Internet to find information on health issues, such as specific diseases, usually start their search from a general search engine, for example, Google. Internet searches such as these may yield results and data of questionable quality and reliability. Health Library is a free-of-charge medical portal on the Internet providing medical information for the general public. Physician's Databases, an Internet evidence-based medicine source, provides medical information for health care professionals (HCPs) to support their clinical practice. Both databases are available throughout Finland, but the latter is used only by health professionals and pharmacies. Little is known about how the general public seeks medical information from medical sources on the Internet, how this behavior differs from HCPs' queries, and what causes possible differences in behavior., Objective: The aim of our study was to evaluate how the general public's and HCPs' information-seeking trends from Internet medical databases differ seasonally and temporally. In addition, we aimed to evaluate whether the general public's information-seeking trends could be utilized for disease surveillance and whether media coverage could affect these seeking trends., Methods: Lyme disease, serving as a well-defined disease model with distinct seasonal variation, was chosen as a case study. Two Internet medical databases, Health Library and Physician's Databases, were used. We compared the general public's article openings on Lyme disease from Health Library to HCPs' article openings on Lyme disease from Physician's Databases seasonally across Finland from 2011 to 2015. Additionally, media publications related to Lyme disease were searched from the largest and most popular media websites in Finland., Results: Both databases, Health Library and Physician's Databases, show visually similar patterns in temporal variations of article openings on Lyme disease in Finland from 2011 to 2015. However, Health Library openings show not only an increasing trend over time but also greater fluctuations, especially during peak opening seasons. Outside these seasons, publications in the media coincide with Health Library article openings only occasionally., Conclusions: Lyme disease-related information-seeking behaviors between the general public and HCPs from Internet medical portals share similar temporal variations, which is consistent with the trend seen in epidemiological data. Therefore, the general public's article openings could be used as a supplementary source of information for disease surveillance. The fluctuations in article openings appeared stronger among the general public, thus, suggesting that different factors such as media coverage, affect the information-seeking behaviors of the public versus professionals. However, media coverage may also have an influence on HCPs. Not every publication was associated with an increase in openings, but the higher the media coverage by some publications, the higher the general public's access to Health Library., (©Samuli Pesälä, Mikko J Virtanen, Jussi Sane, Pekka Mustonen, Minna Kaila, Otto Helve. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 06.11.2017.)

Background: Both health care professionals and nonprofessionals seek medical information on the Internet. Using Web-based search engine searches to detect epidemic diseases has, however, been problematic. Physician's databases (PD) is a chargeable evidence-based medicine (EBM) portal on the Internet for health care professionals and is available throughout the entire health care system in Finland. Lyme borreliosis (LB), a well-defined disease model, shows temporal and regional variation in Finland. Little data exist on health care professionals' searches from Internet-based EBM databases in public health surveillance., Objective: The aim of this study was to assess whether health care professionals' use of Internet EBM databases could describe seasonal increases of the disease and supplement routine public health surveillance., Methods: Two registers, PD and the register of primary health care diagnoses (Avohilmo), were used to compare health care professionals' Internet searches on LB from EBM databases and national register-based LB diagnoses in order to evaluate annual and regional variations of LB in the whole country and in three selected high-incidence LB regions in Finland during 2011-2015., Results: Both registers, PD and Avohilmo, show visually similar patterns in annual and regional variation of LB in Finland and in the three high-incidence LB regions during 2011-2015., Conclusions: Health care professionals' Internet searches from EBM databases coincide with national register diagnoses of LB. PD searches showed a clear seasonal variation. In addition, notable regional differences were present in both registers. However, physicians' Internet medical searches should be considered as a supplementary source of information for disease surveillance., (©Samuli Pesälä, Mikko J Virtanen, Jussi Sane, Jukkapekka Jousimaa, Outi Lyytikäinen, Satu Murtopuro, Pekka Mustonen, Minna Kaila, Otto Helve. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 11.04.2017.)

Since December 2016, excess all-cause mortality was observed in many European countries, especially among people aged ≥ 65 years. We estimated all-cause and influenza-attributable mortality in 19 European countries/regions. Excess mortality was primarily explained by circulation of influenza virus A(H3N2). Cold weather snaps contributed in some countries. The pattern was similar to the last major influenza A(H3N2) season in 2014/15 in Europe, although starting earlier in line with the early influenza season start., (This article is copyright of The Authors, 2017.)

OBJECTIVE To investigate whether comparison by deep or adjusted deep surgical site infection (SSI) rates in orthopedic surgeries are a better basis for feedback to Finnish hospitals than overall SSI rates DESIGN Retrospective cohort study SETTING Hospitals conducting surveillance of hip arthroplasties (HPROs) and knee arthroplasties (KPROs) in the Finnish Hospital Infection Program METHODS We analyzed surveillance data for 73,227 HPROs and 56,860 KPROs performed in 18 hospitals during 1999-2014. For each hospital, the overall, deep, and adjusted deep SSI rates with 95% confidence intervals (CIs) were calculated, and the hospital ranks were simulated in the Bayesian framework. Adjustments were performed using relevant patient and hospital characteristics. The correlation between the median expected hospital ranks in overall versus deep SSI rates and deep vs adjusted deep SSI rates were assessed using Spearman's correlation coefficient ρ. RESULTS For HPRO, the overall SSI rates ranged from 0.92 to 6.83, the deep SSI rates ranged from 0.34 to 1.86, and the adjusted deep hospital-specific SSI rates ranged from 0.37 to 1.85. For KPRO, the overall SSI rates ranged from 0.71 to 5.03, the deep SSI rates ranged from 0.42 to 1.60, and the adjusted deep hospital-specific SSI rates ranged from 0.56 to 1.55. For both procedures, the 95% CIs of the rates between hospitals largely overlapped; only single outliers were detected. Hospital rank did not correlate between overall and deep SSI rates (HPRO, ρ=0.03; KPRO, ρ=0.40), but a correlation was observed in hospital rank for deep and adjusted deep SSI rates (HPRO, ρ=0.85; KPRO, ρ=0.94). CONCLUSION Deep SSI rates may be a better tool for interhospital comparisons than overall SSI rates. Although the adjustment could lead to fairer hospital ranking, it is not always necessary for feedback. Infect Control Hosp Epidemiol 2017;38:423-429.

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.

Background: The ten-valent pneumococcal conjugate vaccine (PCV10) was introduced into the Finnish National Vaccination Program (NVP) in September 2010 with a 2+1 schedule (3, 5, 12 months) without catch-up vaccinations. We evaluated the direct and indirect effects of PCV10 on invasive pneumococcal disease (IPD) among children ≤5 years of age during the first three years after NVP introduction., Methods: We conducted a population-based, observational follow-up study. The cohort of vaccine-eligible children (all children born June 1, 2010 or later) was followed from 3 months of age until the end of 2013. For the indirect effect, another cohort of older children ineligible for PCV10 vaccination was followed from 2011 through 2013. Both cohorts were compared with season- and age-matched reference cohorts before NVP introduction. National, population-based laboratory surveillance data were used to compare culture-confirmed serotype-specific IPD rates in the vaccine target and reference cohorts by using Poisson regression models., Results: The overall IPD rate among vaccine-eligible children was reduced by 80% (95%CI 72 to 85); the reduction in vaccine-type IPD was 92% (95%CI 86 to 95). However, a non-significant increase in non-vaccine type IPD was observed. During 2012-2013, we also observed a 48% (95%CI 18 to 69) reduction in IPD among unvaccinated children 2 to 5 years of age, which was mostly attributable to the ten vaccine serotypes., Conclusions: This is the first population-based study investigating the impact of PCV10 introduction without prior PCV7 use. A substantial decrease in IPD rates among vaccine-eligible children was observed. A smaller and temporally delayed reduction among older, unvaccinated children suggests that PCV10 also provides indirect protection against vaccine-type IPD. Changes in serotype distribution warrant continuous monitoring of potential increases in non-vaccine serotypes.

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.

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.

Several European countries have timely all-cause mortality monitoring. However, small changes in mortality may not give rise to signals at the national level. Pooling data across countries may overcome this, particularly if changes in mortality occur simultaneously. Additionally, pooling may increase the power of monitoring populations with small numbers of expected deaths, e.g. younger age groups or fertile women. Finally, pooled analyses may reveal patterns of diseases across Europe. We describe a pooled analysis of all-cause mortality across 16 European countries. Two approaches were explored. In the ‘summarized’ approach, data across countries were summarized and analysed as one overall country. In the ‘stratified’ approach, heterogeneities between countries were taken into account. Pooling using the ‘stratified’ approach was the most appropriate as it reflects variations in mortality. Excess mortality was observed in all winter seasons albeit slightly higher in 2008/09 than 2009/10 and 2010/11. In the 2008/09 season, excess mortality was mainly in elderly adults. In 2009/10, when pandemic influenza A(H1N1) dominated, excess mortality was mainly in children. The 2010/11 season reflected a similar pattern, although increased mortality in children came later. These patterns were less clear in analyses based on data from individual countries. We have demonstrated that with stratified pooling we can combine local mortality monitoring systems and enhance monitoring of mortality across Europe.

In February and March 2012, excess deaths among the elderly have been observed in 12 European countries that carry out weekly monitoring of all-cause mortality. These preliminary data indicate that the impact of influenza in Europe differs from the recent pandemic and post-pandemic seasons. The current excess mortality among the elderly may be related to the return of influenza A(H3N2) virus, potentially with added effects of a cold snap.

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.

Background: In 2007, part of a drinking water distribution system was accidentally contaminated with waste water effluent causing a gastroenteritis outbreak in a Finnish town. We examined the acute and cumulative effects of this incidence on sick leaves among public sector employees residing in the clean and contaminated areas, and the additional costs of lost workdays due to the incidence., Methods: Daily information on sick leaves of 1789 Finnish Public Sector Study participants was obtained from employers' registers. Global Positioning System-coordinates were used for linking participants to the clean and contaminated areas. Prevalence ratios (PR) for weekly sickness absences were calculated using binomial regression analysis. Calculations for the costs were based on prior studies., Results: Among those living in the contaminated areas, the prevalence of participants on sick leave was 3.54 (95% confidence interval (CI) 2.97-4.22) times higher on the week following the incidence compared to the reference period. Those living and working in the clean area were basically not affected, the corresponding PR for sick leaves was 1.12, 95% CI 0.73-1.73. No cumulative effects on sick leaves were observed among the exposed. The estimated additional costs of lost workdays due to the incidence were 1.8-2.1 million euros., Conclusions: The prevalence of sickness absences among public sector employees residing in affected areas increased shortly after drinking water distribution system was contaminated, but no long-term effects were observed. The estimated costs of lost workdays were remarkable, thus, the cost-benefits of better monitoring systems for the water distribution systems should be evaluated.

Salmonella enterica serotype Bovismorbificans is a rare serotype in Finland. In June 2009, a nationwide outbreak of S. Bovismorbificans infections occurred, and 42 clinical isolates were identified. We conducted a case-control study enrolling 28 cases and 48 matched controls, and found ready-to-eat alfalfa sprouts associated with the infection (odds ratio = 35.2, 95% confidence interval 2.8-435). The sprouts were traced back to a domestic producer, with the seeds originating in Italy. Although finding microbiological evidence for sprouts as a source of this outbreak was very challenging, S. Bovismorbificans was finally found in sprouts germinated in the laboratory, and in soaking and rinse waters during the germination process. The pulsed field gel electrophoresis showed that these isolates were identical to the human outbreak isolates. Before sampling, it is important to mix the seeds well and to take several large-size samples from different seed lots. Instead of analysing seeds, the analysis should be targeted to soaking or rinse water samples and to the sprouts germinated in a laboratory. Accordingly, the sprout producers should only buy seeds that have been analysed for Salmonella. The producers have to include Salmonella testing in their internal quality control to ensure that Salmonella is absent from sprouts placed on the market during their shelf-life. In order to reduce the health hazard caused by sprouts, an effective and safe decontamination procedure should also be developed for the seeds., (© 2011 Blackwell Verlag GmbH.)

Giardia and Cryptosporidium are protozoan parasites that can cause prolonged gastrointestinal infection especially in immunocompromised individuals. We studied the characteristics of giardiasis and cryptosporidiosis cases notified to the Finnish Infectious Disease Registry (FIDR) during 1995-2006, and of persons tested for these parasites in the clinical laboratory of the healthcare district of Helsinki and Uusimaa during 2004-2006. According to reporting, the incidence of both infections was higher in persons residing in the Helsinki area than in other parts of Finland. Persons born abroad were more often tested than were persons born in Finland, and the proportion of the Giardia infected among those tested was very high (14%) in children under the age of five born abroad. Giardia was tested for over 70 times as often as Cryptosporidium, which thus appears to be heavily under tested and therefore underdetected., (© 2011 The Authors. APMIS © 2011 APMIS.)

An inappropriate cross-connection between sewage- and drinking-water pipelines contaminated tap water in a Finnish town, resulting in an extensive waterborne gastroenteritis outbreak in this developed country. According to a database and a line-list, altogether 1222 subjects sought medical care as a result of this exposure. Seven pathogens were found in patient samples of those who sought treatment. To establish the true disease burden from this exposure, we undertook a population-based questionnaire investigation with a control population, infrequently used to study waterborne outbreaks. The study covered three areas, contaminated and uncontaminated parts of the town and a control town. An estimated 8453 residents fell ill during the outbreak, the excess number of illnesses being 6501. Attack rates were 53% [95% confidence interval (CI) 49.5-56.4] in the contaminated area, 15.6% (95% CI 13.1-18.5) in the uncontaminated area and 6.5% (95% CI 4.8-8.8) in the control population. Using a control population allowed us to differentiate baseline morbidity from the observed morbidity caused by the water contamination, thus enabling a more accurate estimate of the disease burden of this outbreak.

Puumala virus (PUUV) causes mild haemorrhagic fever with renal syndrome, a rodent-borne zoonosis. To evaluate the disease burden of PUUV infections in Finland, we analysed data reported by laboratories to the National Infectious Disease Registry during 1995-2008 and compared these with data from other national registries (death, 1998-2007; hospital discharge, 1996-2007; occupational diseases, 1995-2006). A total of 22,681 cases were reported (average annual incidence 31/100,000 population); 85% were in persons aged 20-64 years and 62% were males. There was an increasing trend in incidence, and the rates varied widely by season and region. We observed 13 deaths attributable to PUUV infection (case-fatality proportion 0.08%). Of all cases, 9599 (52%) were hospitalized. Only 590 cases (3%) were registered as occupational disease, of which most were related to farming and forestry. The wide seasonal and geographical variation is probably related to rodent density and human behaviour.

Background: Yersinia enterocolitica (YE) is the causative agent of yersiniosis. YE encompass strains of diverse pathogenicity: YE biotypes 1B and 2-5 are considered pathogenic, whereas biotype 1A is in general considered nonvirulent. Also YE-like species, which can sometimes be misidentified as YE, are considered nonvirulent., Methods: In order to study differences in clinical picture caused by different YE types and their possible sources a case-control study was conducted in 2006. In this case-control study, 295 case-patients with YE or YE-like finding and their 758 controls responded to the questionnaire about symptoms and possible sources of infection., Results: Strains of pathogenic YE bio/serotypes 3-4/O:3 or 2/O:9 were found in 18%, YE biotype 1A in 65% and YE -like strains of 17% of the patients. Patients infected with the strains of pathogenic YE bio/serotypes were younger and had fever more often than those with BT 1A who suffered more from vomiting. Symptoms of reactive arthritis were reported by 10% of pathogenic YE infections, 3% of YE BT 1A, and 0.3% of the controls. Eating or tasting raw or medium done pork was a significant risk factor for pathogenic YE bio/serotype infection (OR 6.6; 95% CI 1.7-24.9) as well as eating in a canteen (OR 3.5; 95% CI 1.6-7.9). Imported fruits and berries were associated with increased risk of YE BT 1A finding., Conclusions: The symptoms of the patients with YE BT 1A differed from yersiniosis caused by the classic pathogenic YE bio/serotypes. In addition, the patients with YE BT 1A had more protracted gastrointestinal disorders and unspecific complaints. Small children were overrepresented in classic pathogenic bio/serotypes while in BT 1A or YE-like species were not found among children younger than two years. This suggests the lacking virulence of the BT 1A strains. We can not, however, rule out the possibility that some strains of genetically heterogeneous group of BT 1A may cause an illness.

Risk of weight change and fluctuation for type 2 diabetes was studied in a prospective study among 20,952 Finnish male smokers aged 50-69 years. Baseline data on lifestyle and medical history were collected, and height and weight measured. Weight was measured thrice after the baseline, 1 year apart. Weight change was defined as the slope of the regression line fitted to the four measurements and weight fluctuation as the root-mean-square-error deviation from this line. Incident cases of diabetes were identified from a national medication reimbursement register; 535 cases up to 9 years' follow-up. The Cox proportional hazards model served to estimate relative risk [RR, 95% confidence interval (CI)]. Weight gain and fluctuation associated with higher risk for diabetes, multivariate RR = 1.77, 95% CI 1.44-2.17, for weight gain of at least 4 kg compared with those of weight change less than 4 kg, and RR = 1.64, 95% CI 1.24-2.17 in the highest weight fluctuation quintile compared to the lowest. These RRs remained similar when weight change and fluctuation were adjusted for each other. Large weight fluctuation increased the risk of diabetes both in men who gained weight (>or=4 kg), had stable weight (+/- <4 kg), and lost weight (>or=4 kg); RR = 2.17, 95% CI 1.60-2.94, RR = 1.47, 95% CI 1.14-1.91, and RR = 2.04, 95% CI 1.47-2.83, respectively, compared to those with stable weight and moderate fluctuation. Short-term weight gain and large weight fluctuation are independent risk factors for diabetes.

Background/objectives: There is convincing evidence that a high dietary fiber intake may lower the risk of coronary heart disease. However, the role of fiber in the prevention of stroke is unclear. We examined the associations of dietary fiber and fiber-rich food intake with risk of stroke within the Alpha-tocopherol, Beta-carotene Cancer Prevention Study., Subjects/methods: Between 1985 and 1988, 26,556 Finnish male smokers aged 50-69 years, who had no history of stroke, completed a dietary questionnaire. During a mean follow-up of 13.6 years, 2702 cerebral infarctions, 383 intracerebral hemorrhages and 196 subarachnoid hemorrhages were ascertained., Results: After adjustment for cardiovascular risk factors and folate and magnesium intakes, there was no significant association between intake of total fiber, water-soluble fiber, water-insoluble fiber, or fiber derived from fruit or cereal sources and risk of any stroke subtype. Vegetable fiber intake, as well as the consumption of fruit, vegetables and cereals, was inversely associated with the risk of cerebral infarction; the multivariate relative risks for the highest quintile of intake as compared with the lowest were 0.86 (95% confidence interval (CI): 0.76-0.99) for vegetable fiber, 0.82 (95% CI: 0.73-0.93) for fruit, 0.75 (95% CI: 0.66-0.85) for vegetables and 0.87 (95% CI: 0.74-1.03) for cereals. Vegetable consumption was inversely associated with risk of subarachnoid hemorrhage (relative risk for highest versus lowest quintile: 0.62; 95% CI: 0.40-0.98), and cereal consumption was inversely associated with risk of intracerebral hemorrhage (relative risk: 0.64; 95% CI: 0.41-1.01)., Conclusions: These findings suggest a beneficial effect of the consumption of fruits, vegetables and cereals on stroke risk.

A nationwide population-based study on community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in Finland during 2004 to 2006 showed that both incidence (1.9/100,000 population) and strain variation increased in comparison to years 1997 to 1999. There were 7 community-associated epidemic and 25 sporadic MRSA strain types. Half of these had Panton-Valentine leukocidin genes.

This study investigated the prevalence of Yersinia enterocolitica (YE) bio/serotypes and YE-like species in clinical stool specimens. The special aim was to find the best methods for accurate identification of YE species and, further, pathogenic strains among YE isolates. Of the 41,848 specimens cultured in ten laboratories during a 12-month period, 473 Yersinia strains were isolated from 462 patients. The strains were identified by 21 biochemical tests, serotyping, colony morphology, as well as by 16S rRNA and gyrB gene sequencing. The most prevalent Yersinia findings were YE biotype 1A (64% of the strains) and pathogenic bio/serotype 4/O:3 (16%). The cold-enrichment increased the number of all isolates, and 25% of the bio/serotype 4/O:3 and 2/O:9 strains were only found by cold-enrichment. In routine diagnostic laboratories, 50% of the YE-like species were identified as YE and in 26% the identification differed from that of the reference laboratory. The microscopic colony identification on CIN agar with positive CR-MOX test, combined with several biochemical tests, identified reliably the pathogenic YE bioserotypes and most YE BT 1A strains, but some strains of the YE-like species were so heterogenic that gene sequencing was the only way to identify them.

Interest in the dietary glycaemic index (GI) and glycaemic load (GL) as risk factors for chronic diseases has grown in recent years but findings have been controversial. We describe the compilation of the GI database for the cohort studies within the Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) Study and the main characteristics associating with diet GI and GL. The ATBC Study enrolled 29 133 male smokers aged 50-69 years who filled in a dietary history questionnaire upon study entry. The dietary data included 1097 foods, of which 195 foods with no or a negligible amount of available carbohydrates were assigned a GI of zero. Based on preset methodological criteria for published GI studies, the GI value of a similar food was available for 130 foods, and the GI of related food was assigned to 360 foods. The GI values of these foods served in the GI calculation of 412 composite foods. The median diet GI among the ATBC Study participants was 67.3 (interquartile range 64.8-70.0), and the median diet GL was 175 (interquartile range 158-192). The intakes of carbohydrates, protein and fat decreased, and the intake of fibre increased, with increasing GI. The GL showed a positive correlation with intakes of carbohydrates and dietary fibre and a negative correlation with intakes of protein and fat. The GI studies available that fulfilled the minimum methodological requirements cover a sufficient amount of foods to form a meaningful GI database for epidemiological study. This, however, requires the availability of GI values for relevant local carbohydrate-containing foods.

Background: Consumption of milk and other dairy foods has been associated with reduced risk of stroke, although not all studies have shown this consistently., Methods: We examined the association between dairy food intake and risk of stroke subtypes within the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study. Between 1985 and 1988, 26,556 Finnish male smokers aged 50-69 years who had no history of stroke completed a food frequency questionnaire. We used Cox proportional hazards models to estimate relative risks (RRs) and 95% confidence intervals (CIs), adjusted for potential confounders., Results: During a mean follow-up of 13.6 years, 2702 cerebral infarctions, 383 intracerebral hemorrhages, and 196 subarachnoid hemorrhages were ascertained. We observed positive associations between whole milk intake and risk of intracerebral hemorrhage (RR = 1.41 for the highest vs. lowest quintile of intake; 95% CI = 1.02-1.96) and between yogurt intake and subarachnoid hemorrhage (RR = 1.83 for the highest vs. lowest quintile of intake; 95% CI = 1.20-2.80). Men in the highest quintile of cream intake had a moderate decreased risk of cerebral infarction (0.81; 0.72-0.92) and intracerebral hemorrhage (0.72; 0.52-1.00). There were no strong associations between intakes of total dairy, low-fat milk, sour milk, cheese, ice cream, or butter and risk of any stroke subtype., Conclusions: These findings suggest that intake of certain dairy foods may be associated with risk of stroke.

We evaluated risk factors for death among hospitalised patients with healthcare-associated infections (HCAIs) using the McCabe classification and Charlson index to predict mortality. The study consisted of a cohort of 703 patients with HCAIs and 7531 patients without HCAI in acute care hospitals participating in the Finnish national prevalence survey in 2005. We used Centers for Disease Control and Prevention definitions for HCAIs and recorded the McCabe classification for comorbidity. We used the date from the prevalence survey and the patient's national identity code in order to retrieve data from the National Hospital Discharge Registry on discharge diagnoses (International Classification of Diseases-10 codes) for the Charlson index and the dates of death from the National Population Information System. Of all inpatients, 425 (5.2%) died within 28 days from the prevalence survey date; the death rate was higher in HCAI patients than in those without HCAI (9.8% vs 4.7%, P<0.001). In the multivariate regression analysis age >65 years, intensive care, McCabe classification and Charlson index, gastrointestinal system infection and pneumonia/other lower respiratory tract infections were independent predictors for death. The survival analysis, when adjusted by McCabe class or Charlson index, showed that HCAI reduced survival only among patients without severe underlying diseases. Certain types of HCAI increased the risk of death. The McCabe classification had advantages over the Charlson index as a predictor of death, because it was easier to collect from a prevalence survey.

The associations of dietary folate, vitamin B(6), vitamin B(12), and methionine intakes with risk of stroke subtypes were examined among 26,556 male Finnish smokers, aged 50-69 years, enrolled in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study. Dietary intake was assessed at baseline by using a validated food frequency questionnaire. During a mean follow-up of 13.6 years, from 1985 through 2004, 2,702 cerebral infarctions, 383 intracerebral hemorrhages, and 196 subarachnoid hemorrhages were identified from national registers. In analyses adjusting for age and cardiovascular risk factors, a high folate intake was associated with a statistically significant lower risk of cerebral infarction but not intracerebral or subarachnoid hemorrhages. The multivariate relative risk of cerebral infarction was 0.80 (95% confidence interval: 0.70, 0.91; p(trend) = 0.001) for men in the highest versus lowest quintile of folate intake. Vitamin B(6), vitamin B(12), and methionine intakes were not significantly associated with any subtype of stroke. These findings in men suggest that a high dietary folate intake may reduce the risk of cerebral infarction.

Background: A high intake of magnesium, calcium, and potassium and a low intake of sodium have been hypothesized to reduce the risk of stroke. However, prospective data relating intake of these minerals to risk of stroke are inconsistent., Methods: We examined the relationship of dietary magnesium, calcium, potassium, and sodium intake with risk of stroke in a cohort of 26 556 Finnish male smokers, aged 50 to 69 years, who were free from stroke at baseline. Dietary intake was assessed at baseline using a detailed and validated food frequency questionnaire. During a mean follow-up of 13.6 years (1985-2004), 2702 cerebral infarctions, 383 intracerebral hemorrhages, and 196 subarachnoid hemorrhages were identified in the national registries., Results: After adjustment for age and cardiovascular risk factors, a high magnesium intake was associated with a statistically significant lower risk of cerebral infarction but not with intracerebral or subarachnoid hemorrhages. The multivariate relative risk of cerebral infarction was 0.85 (95% confidence interval, 0.76-0.97; P for trend = .004) for men in the highest quintile of magnesium intake compared with those in the lowest quintile. The inverse association between magnesium intake and cerebral infarction was stronger in men younger than 60 years (relative risk, 0.76; 95% confidence interval, 0.64-0.89; P for interaction = .02). Calcium, potassium, and sodium intake was not significantly associated with risk of any subtype of stroke (P for trend > .05)., Conclusion: These findings in male smokers suggest that a high magnesium intake may play a role in the primary prevention of cerebral infarction.

Aims/hypothesis: Type 2 diabetes is associated with reduced antioxidant defence. Only a few human studies have investigated the role of antioxidants in the pathogenesis of diabetes. This study aimed to examine whether alpha-tocopherol or beta-carotene affected the occurrence of type 2 diabetes., Methods: In the Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) Study, a double-blind, controlled trial, 29,133 male smokers aged 50-69 years were randomised to receive either alpha-tocopherol (50 mg/day) or beta-carotene (20 mg/day) or both agents or placebo daily for 5-8 years (median 6.1 years). Baseline serum samples were analysed for alpha-tocopherol and beta-carotene using HPLC. Cases of diabetes were identified from a nationwide Finnish registry of patients receiving drug reimbursement for diabetes. Of 27,379 men without diabetes at baseline, 705 men were diagnosed with diabetes during the follow-up of up to 12.5 years., Results: Baseline serum levels of alpha-tocopherol and beta-carotene were not associated with the risk of diabetes in the placebo group: the relative risk (RR) between the highest and lowest quintiles of alpha-tocopherol was 1.59 (95% CI 0.89-2.84) and that for beta-carotene was 0.66 (95% CI 0.40-1.10). Neither supplementation significantly affected the incidence of diabetes: the RR was 0.92 (95% CI 0.79-1.07) for participants receiving alpha-tocopherol compared with non-recipients and 0.99 (95% CI 0.85-1.15) for participants receiving beta-carotene compared with non-recipients., Conclusions/interpretation: Neither alpha-tocopherol nor beta-carotene supplementation prevented type 2 diabetes in male smokers. Serum levels of alpha-tocopherol and beta-carotene were not associated with the risk of type 2 diabetes.

Background: Fruit and vegetable intakes have been associated with a reduced risk of colon cancer; however, in more recent studies associations have been less consistent. Statistical power to examine associations by colon site has been limited in previous studies., Methods: Fruit and vegetable intakes in relation to colon cancer risk were examined in the Pooling Project of Prospective Studies of Diet and Cancer. Relative risks (RRs) and 95% confidence intervals (CIs) were estimated separately in 14 studies using Cox proportional hazards model and then pooled using a random-effects model. Intakes of total fruits and vegetables, total fruits, and total vegetables were categorized according to quintiles and absolute cutpoints. Analyses were conducted for colon cancer overall and for proximal and distal colon cancer separately. All statistical tests were two-sided., Results: Among 756,217 men and women followed for up to 6 to 20 years, depending on the study, 5838 were diagnosed with colon cancer. The pooled multivariable RRs (95% CIs) of colon cancer for the highest versus lowest quintiles of intake were 0.91 (0.82 to 1.01, P(trend) = .19) for total fruits and vegetables, 0.93 (0.85 to 1.02, P(trend) = .28) for total fruits, and 0.94 (0.86 to 1.02, P(trend) = .17) for total vegetables. Similar results were observed when intakes were categorized by identical absolute cut points across studies (pooled multivariable RR = 0.90, 95% CI = 0.77 to 1.05 for 800 or more versus <200 g/day of total fruits and vegetables, P(trend) = .06). The age-standardized incidence rates of colon cancer for these two intake categories were 54 and 61 per 100,000 person-years, respectively. When analyzed by colon site, the pooled multivariable RRs (95% CIs) comparing total fruit and vegetable intakes of 800 or more versus less than 200 g/day were 0.74 (0.57 to 0.95, P(trend) = .02) for distal colon cancers and 1.02 (0.82 to 1.27, P(trend) = .57) for proximal colon cancers. Similar site-specific associations were observed for total fruits and total vegetables., Conclusion: Fruit and vegetable intakes were not strongly associated with colon cancer risk overall but may be associated with a lower risk of distal colon cancer.

Background and Objective: The validity of food frequency questionnaires (FFQs) in measuring food consumption and nutrient intake has to be assessed. The objective of this study was to assess the validity of a 128-item FFQ in specific subgroups of Finnish adults., Methods: The study included 294 subjects (137 men and 157 women). A 3-day food record was used as the reference method., Results: The mean intake of all nutrients except alcohol was higher measured with the FFQ than with the food records. In general, the Pearson correlations for energy adjusted nutrients between the FFQ and the food records were higher in women than in men. The correlations ranged from 0.14 (retinol) to 0.66 (fiber and alcohol) in men, and from 0.20 (long-chain n-3 fatty acids) to 0.70 (alcohol) in women. The results in subgroups showed that measuring nutrient intakes is more difficult among younger (30-50 years) women and overweight men and women than among others., Conclusions: The study showed that the FFQ is a useful tool in epidemiologic studies in measuring the diet of Finnish adults given that the problems among specific subgroups are taken into account in interpretation.

The lignan enterolactone produced by the intestinal microflora from dietary precursors has been hypothesized to protect against coronary heart disease. The present study examined the association between serum enterolactone concentration and the risk of coronary heart disease. A prospective case-cohort study was conducted among male smokers randomized to receive a placebo supplement in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study (1986-1999). Serum enterolactone concentrations were measured by the gas chromatography-mass spectrometry method in serum collected at trial baseline from 340 men diagnosed with nonfatal myocardial infarction (n = 205) or coronary death (n = 135) during follow-up and from the randomly selected subcohort of 420 subjects. The classic risk factors-adjusted rate ratios for all coronary heart disease events in increasing quintiles of enterolactone were 1.00 (referent), 0.85 (95% confidence interval (CI): 0.51, 1.43), 0.59 (95% CI: 0.35, 1.00), 0.69 (95% CI: 0.40, 1.16), and 0.63 (95% CI: 0.33, 1.11), and the p(trend) was 0.07. For the highest versus the lowest quintile of enterolactone, the rate ratios for nonfatal myocardial infarction and coronary death were 0.67 (95% CI: 0.37, 1.23; p(trend) = 0.10) and 0.57 (95% CI: 0.26, 1.25; p(trend) = 0.18), respectively. In conclusion, only weak support for the association between serum enterolactone concentration and coronary heart disease was found.

A total of 29,133 male smokers, aged 50-69 years, were recruited into the Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) Study in 1984-1988. The nationwide Finnish Cancer Registry (FCR) recorded 5944 incident cases of cancer in this cohort through the end of 1999. Compared with the FCR data of the entire Finnish male population of same age the standardized incidence ratio (SIR) of total cancer in the ATBC cohort was 1.55 [95% confidence interval (CI) 1.51-1.59]. There was a significant excess of established smoking-related malignancies, such as lung cancer (SIR 2.45, 95% CI 2.35-2.56), and cancers of the tongue, mouth, pharynx, larynx, oesophagus, pancreas, stomach, liver, urinary bladder and kidney. In addition to these sites, cancers of the prostate and colon were slightly more common in the ATBC cohort than in the total Finnish male population (SIR 1.10, 95% CI 1.04-1.18 and SIR 1.14, 95% CI 1.00-1.30, respectively). In conclusion, the risk of many cancers was significantly higher in the ATBC Study cohort compared with the total Finnish male population of same age. In addition to the well known smoking-related cancers, cigarette smoking may increase slightly the risk of colon and prostate cancer, too.

Objective: Only a few consistent findings on individual foods or nutrients that influence breast cancer risk have emerged thus far. Since people do not consume individual foods but certain combinations of them, the analysis of dietary patterns may offer an additional aspect for assessing associations between diet and diseases such as breast cancer. It is also important to examine whether the relationships between dietary patterns and breast cancer risk are consistent across populations., Methods: We examined the risk of breast cancer with two dietary patterns, identified as "Vegetables" (VEG) and "Pork, Processed Meat, Potatoes" (PPP), common to all cohorts of the DIETSCAN project. During 7 to 13 years of follow-up, three of the cohorts--the Netherlands Cohort Study on diet and cancer (NLCS), the Swedish Mammography Cohort (SMC), and the Ormoni e Dieta nella Eziologia dei Tumori (Italy-ORDET)--provided data on 3271 breast cancer cases with complete information on their baseline diet measured by a validated food frequency questionnaire., Results: After adjustment for potential confounders, VEG was not associated with the risk of breast cancer across all cohorts. PPP was also not associated with the risk of breast cancer in SMC and ORDET, but a high PPP score tended to be inversely associated with breast cancer in the NLCS study (RR = 0.69; 95% CI, 0.52-0.92, highest versus lowest quartile). PPP differed in one aspect between the cohorts: butter loaded positively on the pattern in all cohorts except NLCS, in which butter loaded negatively and appeared to be substituted by low-fat margarine loading positively., Conclusion: In general, the dietary patterns showed consistent results across the three cohorts except for the possible protective effect of PPP in the NLCS cohort, which could be explained by a difference in that pattern for NLCS. The results supported the suggestion derived from traditional epidemiology that relatively recent diet may not have an important role in the etiology of breast cancer.

Of the few studies that have examined alcohol consumption in relation to risk of renal cell cancer (RCC), most are case-control studies. The extent to which alcohol affects RRC risk is unclear. We prospectively examined the association between total alcohol intake as well as specific types of alcoholic beverage and RCC in a large cohort of Finnish male smokers. Men from the Alpha-Tocopherol, BetaCarotene (ATBC) Cancer Prevention Study were followed for 12 years and RCC cases were identified. Alcohol consumption was assessed at baseline using a questionnaire previously shown to be both reproducible and valid. Cox proportional hazards modeling was used to adjust simultaneously for known or suspected risk factors for RCC. We ascertained 195 incident cases of RCC. In multivariate analysis, the relative risks and 95% confidence intervals (CI) of RCC according to increasing quartiles of total alcohol intake were 1.0, 0.91 (0.62-1.33), 0.94 (0.64-1.38), and 0.53 (0.34-0.83), respectively (P value for trend = 0.005); for spirit consumption, 1.0, 0.93 (0.63-1.Fspiait39), 0.84 (0.58-1.20), and 0.55 (0.36-0.85) (P for trend = 0.02); and for beer intake, 1.0, 1.22 (0.85-1.76), 0.83 (0.57-1.22), and 0.55 (0.36-0.85) (P for trend = 0.003). Too few people in this cohort drank wine to assess its association with risk of RCC. These data suggest that alcohol consumption is associated with decreased risk of RCC in male smokers. Because most of the risk reductions were seen at the highest quartile of alcohol intake and alcohol is a risk factor for a number of cancers particularly among smokers, these data should be interpreted with caution.

Background: An analysis of dietary patterns or combinations of foods may provide insight regarding the influence of diet on the risk of colon and rectal cancer., Objective: A primary aim of the Dietary Patterns and Cancer (DIETSCAN) Project was to develop and apply a common methodologic approach to study dietary patterns and cancer in 4 European cohorts: the Alpha-Tocopherol Beta-Carotene Cancer Prevention Study (Finland-ATBC), the Netherlands Cohort Study (NLCS) on Diet and Cancer, the Swedish Mammography Cohort (SMC), and the Ormoni e Dieta nella Eziologia dei Tumori (Italy-ORDET). Three cohorts (ATBC, NLCS, and SMC) provided data on colon and rectal cancer for the present study., Design: The cohorts were established between 1985 and 1992; follow-up data were obtained from national cancer registries. The participants completed validated semiquantitative food-frequency questionnaires at baseline., Results: Exploratory factor analysis, conducted within each cohort, identified 3-5 stable dietary patterns. Two dietary patterns-Vegetables and Pork, Processed Meats, Potatoes (PPP)-were common across all cohorts. After adjustment for potential confounders, PPP was associated with an increased risk of colon cancer in the SMC women (quintile 4(multivariate) relative risk: 1.62; 95% CI: 1.12, 2.34; P for trend = 0.01). PPP was also associated with an increased risk of rectal cancer in the ATBC men (quintile 4(multivariate) relative risk: 2.21; 95% CI: 1.07, 4.57; P for trend = 0.05). Neither pattern was associated with the risk of colon or rectal cancer in the NLCS women and men., Conclusion: Although certain dietary patterns may be consistent across European countries, associations between these dietary patterns and the risk of colon and rectal cancer are not conclusive.