Date: Mon 28 Mar 2016
Source: Source: GIDEON (Global Infectious Disease & Epidemiology Network) [edited]
<http://www.gideononline.com>

Re: ProMED-mail Lyme disease - Finland: underreporting
http://promedmail.org/post/20160328.4122126
----------------------------------------------------------------------
A recent report on ProMED-mail that Lyme disease is an under-reported disease in Finland is disturbing. Officially-reported rates have been increasing rapidly since the year 2000, and already exceed those of the United States by more than 300 percent! [1,2]. See graph at
<http://www.gideononline.com/wp/wp-content/uploads/Lyme-Finland.png>

References
----------
1. Berger S: Lyme Diseases - Global Status, 2016. 83 pages, 66 graphs, 882 references. Gideon e-books,
<http://www.gideononline.com/ebooks/disease/lyme-disease-global-status/>.
2. Berger S: Infectious Diseases of Finland, 2016. 482 pages, 130 graphs, 2035 references. Gideon e-books,
<http://www.gideononline.com/ebooks/country/infectious-diseases-of-finland/>.
------------------------------------
Communicated by:
Dr Steve Berger
Geographic Medicine
Tel Aviv Medical Center
Israel
mberger@post.tau.ac.il
===================
[ProMED-mail thanks Dr Berger for his continued contributions.

The reported incidence for confirmed Lyme disease in the US for 2014, the most recent year for which data are available, is 25,359 (incidence rate 7.9 per 100,000) (<http://www.cdc.gov/lyme/stats/tables.html>). The reported incidence for Lyme disease given in the news report for Finland in 2015 is 1900 (about 35 per 100,000); this incidence rate in Finland is over 4-fold higher than the reported US incidence rate, as Dr Berger points out.

However, the CDC estimates that the total number of people who develop Lyme disease each year in the US is actually 10 times higher than the yearly reported number or 253 590 (79 per 100 000) for 2014 (<http://www.cdc.gov/media/releases/2013/p0819-lyme-disease.html>). The news report says that one estimate for the actual number of Lyme cases in Finland in 2015 is 4000-5000 (74-93 per 100,000) and another estimate is 8000 (148 per 100,000), that is, the estimates for the actual yearly incidence rate of Lyme cases in Finland may be up to almost 2-fold higher than the estimate for the actual incidence rate of Lyme cases in the US. - ProMED Mod.ML]

[A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/promed/p/118>.]
Date: Fri 25 Mar 2016
Source: Uutiset [edited]
<http://yle.fi/uutiset/professor_lyme_disease_cases_likely_underreported/8769258>

According to the National Institute for Health and Welfare THL, there were a bit less than 2000 cases of Lyme disease reported in Finland in 2015, but an infectious disease specialist says the actual number of cases could be as high as 8000.

Lyme disease, which is also known as Lyme borreliosis, is an infectious disease spread by bacteria-carrying ticks. When a person is infected, a circular rash develops around the bite area of the skin about a week after the bite. Milder, early symptoms can include headache and fever, but left untreated, the disease can cause partial facial paralysis, joint pain and a variety of other symptoms. There is also ongoing research that left untreated, the disease has the potential to develop into a chronic illness.

Jarmo Oksi, a specialist in infectious diseases and professor at the University of Turku, says that THL's figure of some 1900 incidents of Lyme disease last year [2015] only reflects cases where diagnoses were reached through blood tests. When patients have the telltale ring-shaped skin rash that marks the onset of the illness, physicians usually just skip the blood test. "And in most cases, that's what happens," Oksi says.

The doctor makes a diagnosis of Lyme disease and prescribes the patient antibiotics. Additionally, when the malady is still its early stages, sometimes a blood test cannot confirm Lyme, he says. "This means we should take THL's figures and multiply them by 4," Oksi estimates.

Jussi Sane, an epidemiologist at THL agrees with Oksi's assessment that the agency's statistics don't reflect the real number but says the number is likely closer to between 4 and 5000 cases. "THL only records more advanced cases of Lyme disease, when the illness has spread throughout the body," Sane says, adding that the agency is currently examining exactly how widespread Lyme disease actually is. Oksi says he thinks the increased incidents of Lyme disease in Finland is directly related to an increase in tick populations, which is caused by an increasingly milder climate.

A colder winter this year [2016] has some people wondering whether the tick population would be diminished this summer, but Oksi says probably not. They'll be back this summer. "This past winter won't affect them. Ticks can survive harsh winters, and this winter just hasn't been harsh enough to have had an effect," he says.

There are 2 species of ticks in Finland, the common tick and the taiga tick, both of which can spread Lyme disease and tick-borne encephalitis. It's thanks to research at the University of Turku that experts know there has been an increase of at least taiga tick populations in Finland. As part of a study in 2015, people from across the country sent the university some 20 000 ticks, and researchers learned that there were even more taiga ticks in Finland than they previously thought. Anecdotal evidence points to an increase in ticks in general, but there are currently no official figures on how much tick populations have changed, Oksi says.
=====================
[_Borrelia burgdorferi_ sensu lato is a group of genetically and phenotypically distinct spirochetal bacterial species, not all of which are known to cause human disease (<http://cmr.asm.org/content/12/4/633.long>). _Borrelia_ species are differentially distributed worldwide. In Europe, most commonly _B. garinii_, and _B. afzelii_ cause Lyme borreliosis in humans; whereas, in North America, _B. burgdorferi_ sensu stricto causes Lyme borreliosis. (A new _B. burgdorferi_ sensu lato genospecies (candidatus _B. mayonii_) has been reported to occur in patients with Lyme disease in the upper Midwestern US. See ProMED-mail post Lyme disease - USA (02): (upper Midwest region) new Borrelia species http://promedmail.org/post/20160222.4040006.)

Different clinical manifestations are often associated with these different genospecies. Erythema migrans (EM) and Lyme arthritis are more common in the United States than in Europe. In the U.S., as many as 80-90 percent of patients with Lyme disease develop the characteristic EM rash (<http://www.cdc.gov/lyme/signs_symptoms/index.html>). Whereas neuroborreliosis [or Lyme affecting the nervous system], borrelial lymphocytoma [bluish-red nodular swelling], and acrodermatitis chronica atrophicans occur more frequently in Europe.

Genetic differences between species within the _B. burgdorferi_ sensu lato complex may result in problems with the serodiagnosis of Lyme borreliosis, especially in regards to immunoblot assays, although it may be less important for enzyme-linked immunosorbent assays (ELISAs) (<http://jid.oxfordjournals.org/content/169/2/313.abstract?ijkey=575b92fb19da9611b73c374a6947577b14843bee&keytype2=tf_ipsecsha>). However, ELISAs using the C6 peptide are reported to overcome these problems (<http://cid.oxfordjournals.org/content/57/3/333.long>).

However, laboratory testing is not indicated for the diagnosis of EM, because EM is an early manifestation of Lyme disease, which usually begins one to 2 weeks after a tick bite, often before serologic tests become positive. Clinical findings are sufficient for the diagnosis of erythema migrans (<http://cid.oxfordjournals.org/content/43/9/1089.full>). Laboratory-based reporting will fail to capture EM, and when clinicians fail to report EM, Lyme disease will be underreported, the extent of which will depend on the frequency of EM in the spectrum of clinical manifestations of Lyme disease in that region of the world.

In North America, Lyme disease is transmitted by the bite of the hard-bodied tick species _Ixodes scapularis_ and _Ixodes pacificus_. In Europe, the vectors are _Ixodes ricinus_ and the taiga tick (_Ixodes persulcatus_). - ProMED Mod.ML]

[Tick pics at
<https://hnhu.org/wp-content/themes/hnhu/_common/images/tick-differences.jpg>. - ProMED Mod.JW]

[A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/promed/p/118>.]
Date: Mon, 14 Sep 2015 18:19:02 +0200 (METDST)

Helsinki, Sept 14, 2015 (AFP) - At least 20 Finnish employee unions have announced plans to join a massive strike set for Friday against the government's harsh austerity measures, from cutting back holidays to slashing overtime pay, officials said on Monday.

The influential Transport Workers' Union AKT said it would bring the Nordic country to a virtual standstill by stopping all bus and lorry transports and by shutting down harbours on Friday.   "With the demonstration of the  employee organisations we will defend the labour parties' free right to forge collective agreements and resist the unilateral coercive laws with which (Prime Minister) Sipila's government has proposed to dilute the employees' terms and conditions," AKT said in a statement.

The conciliator general's agency, which receives the unions' strike notices, told AFP it did not have the final count of the participating unions yet as it kept receiving more notices.   By Monday afternoon, unions representing police, metal workers, air traffic controllers, cabin crew, sales personnel and restaurant workers had announced their participation in the strike.   All rail traffic is also to stop on Friday and some schools and daycare centres will be closed.     Last week Finland's centre-right pro-austerity government unveiled harsh cutbacks to workers' benefits in a bid to revive the country's slumping economy.

The measures include cutting back long holidays, halving overtime compensation and reducing Sunday work compensation from 100 to 75 percent.   Some paid bank holidays will also be eliminated, and employees will not be paid for their first sick leave day.   The unions took no immediate action after the government's announcement, but agreed to have a common anti-austerity rally on Friday in Helsinki.   Finland, once a top performer in the eurozone, has seen its economy crumble under the effects of its rapidly ageing population and declines in key sectors of its economy such as forestry and the technology industry.

The country has a four-decade long tradition of forging tripartite compromises, in which employers' organisations, labour unions and the government sit down to agree on taxes, wages and other conditions such as working hours.   But now the unions accuse the government of attacking their freedom of agreement and of stipulating the maximum conditions that can be agreed upon in certain areas of collective agreements.

"This is an exceptionally hard blow against Finnish society which has for a long time been based on consensus. This strikes at the very heart of freedom of agreement," Jarkko Eloranta, chair of the Trade Union for the Public and Welfare Sectors JHL said in a statement.

During Finland's last recession in the 1990s, unions mainly refrained from organising strikes but tens of thousands of people participated in demonstrations against the government's cuts to public spending.   But in a poll by Finnish tabloid Iltalehti last week, more than 70 percent of over 1,000 respondents were fully or partly in favour of the cuts, and more than 20 percent said the measures were still insufficient.
Date: Thu 14 Aug 2014
Source: Press release, University of Jyvaskyla, Finland [edited]
<https://www.jyu.fi/en/news/archive/2014/08/tiedote-2014-08-14-11-35-32-870428>

A visiting scientist at the University of Jyvaskyla died on Monday last week [11 Aug 2014] after infection by Puumala virus. She got the infection while making laboratory and field studies on bank voles at the Konnevesi Research Station.

The virus is common in Central Finland in the bank vole, which is an important research target of the Department of Biological and Environmental Science. Because Puumala virus infections are common in Central Finland, the security arrangements of the research are very strict.
======================
[According to the Israeli daily Yediot Acharonot, the female victim was a 36-year-old scientist from Israel engaged in animal behavioural ecology research (<http://www.mynet.co.il/articles/0,7340,L-4558471,00.html>, in Hebrew).

Puumala virus, the most common Hantavirus (family Bunyaviridae) in Europe, is a causative agent of hemorrhagic fever with renal syndrome (PUUV-HFRS) or nephropathia epidemica (NE). It has been detected widely in Europe, excluding the British Isles, southern Mediterranean areas, and the very northernmost tundra regions. This parallels (except for the British Isles) the distribution of the main (symptomless) carrier of PUUV, the bank vole (_Myodes glareolus_, previously known as _Clethrionomys glareolus_; picture at <http://en.wikipedia.org/wiki/Bank_vole#mediaviewer/File:R%C3%B6telmaus.jpg>). PUUV is very common in Finland.

The clinical course of NE caused by PUUV is generally regarded to be milder than haemorrhagic fever with renal syndrome caused by other hantaviruses. The current tragic case may indicate that the pathogenicity of this hantavirus may have been underestimated. - ProMed Mod.AS]

[ProMed Mod.CP commented, "haemorrhagic fever with renal failure syndrome (HFRS) occurs mainly in Europe and Asia and is characterized by fever and renal failure associated with haemorrhagic manifestations. [HFRS] is caused by airborne contact with secretions from rodent hosts infected with the group of viruses belonging to the genus _Hantavirus_ of the family _Bunyaviridae_. In Europe, HFRS is caused by hantaviruses: Puumala virus (PUUV), carried by the bank vole (_Myodes glareolus_); Dobrava virus (DOBV), carried by the yellow-necked mouse (_Apodemus flavicollis_)." - ProMed Mod.LM]

[A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/promed/p/118>.]
Date: Thu 17 Apr 2014
Source: Svenska Yle [in Swedish, machine transl., edited]
<http://svenska.yle.fi/artikel/2014/04/17/prover-visar-obehandlad-mjolk-inneholl-bakterier>

The 1st results from milk samples at a farm in Askola, Finland taken 7 Apr 2014 revealed _Yersinia pseudotuberculosis_ and _Campylobacter jejuni_.

The number of people who drank milk from Uljaan tilamaito and experienced symptoms has increased in Porvoo and in the neighbouring municipalities (Askola, Lovisa, Borgnas and Sipoo). There are now 19 confirmed cases of yersiniosis. Campylobacteriosis has so far been isolated from a total of 8 people. Investigations are still on-going for about 20 people.

Uljaan tilamaito pulled away all unpasteurized milk from the shops in early April 2014.
=======================
[In 2013, a review of the issue of raw milk ingestion was addressed (Claeys WL, Cardoen S, Daube G, et al: Raw or heated cow milk consumption: Review of risks and benefits. Food Control 2013; 31(1): 251-62). The paper is available at: <http://dx.doi.org/10.1016/j.foodcont.2012.09.035>.

The abstract, introduction, and conclusions are given below with the citations removed.

"Abstract
---------
In the context of the prevailing trend toward more natural products, there seems to be an increasing preference for raw milk consumption as raw milk is associated with several perceived health benefits that are believed to be destroyed upon heating. However, many human pathogens can be isolated from raw cow milk. The prevalence of foodborne pathogens in raw cow milk varies, but their presence has been demonstrated in many surveys and foodborne infections have been repeatedly reported for _Campylobacter_, _Salmonella_ spp. and human pathogenic verocytotoxin-producing _Escherichia coli_ [VTEC]. In industrialized countries, milk-borne and milk product-borne outbreaks represent 2-6 percent of the bacterial foodborne outbreaks.

The aim of this review is to present scientifically sound data regarding the risks and benefits related to the consumption of raw and heated cow milk. Both microbiological aspects (such as, the prevalence of milk-borne pathogens, pathogen growth inhibition by antimicrobial systems and by lactic acid producing bacteria, probiotic bacteria, etc.) and nutritional or health aspects (nutritional value, immunity, allergies, lactose intolerance, diabetes, milk digestibility, etc.) are considered.

As such, it is demonstrated that consumption of raw milk poses a realistic health threat due to a possible contamination with human pathogens. It is therefore strongly recommended that milk should be heated before consumption. With the exception of an altered organoleptic profile [taste], heating (in particular ultra high temperature and similar treatments) will not substantially change the nutritional value of raw milk or other benefits associated with raw milk consumption.

Introduction
------------
The consumption of raw milk is not well-documented, but in the context of the current trend toward "consuming natural" and "purchasing locally", raw milk consumption is becoming more popular. This is nourished by the perception that heating destroys the nutritional and health benefits of milk, and can even induce some detrimental effects. However, due to its high nutritional value together with the neutral pH and high water activity [content?], raw milk serves as an excellent growth medium for different micro-organisms, whose multiplication depends mainly on temperature and on competing micro-organisms and their metabolic products. In order to guarantee its microbial safety and to prolong its shelf-life, milk is heat treated.

The impact of milk pasteurization on public health can be clearly illustrated by means of historical data. Before 1938, an estimated 25 percent of all foodborne and waterborne disease outbreaks in the USA were associated with milk, whereas nowadays, the percentage of such outbreaks associated with milk is estimated to be below 1 percent. Between 1880 and 1907, 29 milk-borne outbreaks were reported on average each year in the USA. With the adoption of pasteurization in 1938, milk-borne diseases dropped to only 46 outbreaks during the 19-year period from 1973 to 1992, corresponding to an average of 2.4 outbreaks each year. A recent report of the USA CDC indicates that the vast majority of milk-borne outbreaks in the USA are in states that permit the sale of raw milk. In England and Wales, the great majority of milk-borne outbreaks during the 1980s were attributed to the consumption of raw milk. In Scotland, a similar situation existed until the sale of unpasteurized milk was prohibited in 1983, which led to a significant drop of the incidence of diseases related to liquid milk consumption.

In the mid-20th century, the main illnesses associated with raw milk consumption were brucellosis and tuberculosis. These have been eradicated as milk-borne diseases in developed countries, mainly through herd certification programs which included culling of infected animals, the installation of refrigerated bulk tanks for milk collection on farms, and the introduction of pasteurization. In the past, pasteurization conditions were standardized based on the destruction of _Mycobacterium bovis_, a relatively heat-resistant non-sporogenic bacterium that formerly was among the most serious pathogenic bacteria present in milk. Pasteurization standards today are based upon the destruction of _Coxiella burnetii_ the most heat-resistant milk-borne zoonotic pathogen known. In the past 30 years, several previously unrecognized foodborne bacterial infections, including infection with _Campylobacter jejuni_, _Listeria monocytogenes_, and _Escherichia coli_ strain O157 (or more general verocytotoxin-producing pathogenic _E. coli_ [VTEC]), have emerged as significant causes of human morbidity and mortality. Pathogens mainly present in raw milk today are, among others, _C. jejuni_, _Salmonella_ spp., _Staphylococcus aureus_, _Listeria monocytogenes_, pathogenic _E. coli_ and _Yersinia enterocolitica_.

In Europe, the current regulatory microbial criteria for raw cow milk are less than or equal to 100 000 colony forming units (cfu)/ml for plate count (at 30 deg C/86 deg F) and less than or equal to 400,000 cfu/ml for somatic cells, as is stipulated in Regulation (EC) 853/2004 laying down specific hygiene rules on the hygiene of foodstuffs. In this Regulation, health requirements for production animals and hygienic requirements on milk production holdings (such as, regarding premises and equipment, hygiene during milking, collection, and transport, staff hygiene) are established as well. In general, raw milk intended for human consumption must meet the requirements of the General Food Law (Regulation (EC) 178/2002) and be free of pathogens. Even though improvements in hygiene resulted in routine production of raw cow milk with less than 20 000 cfu (total flora)/ml), this does not guarantee raw milk to be free of pathogens. In approximately 1-6 percent of the human outbreaks reported in developed countries, milk has been identified as the vehicle of infection. An overview of foodborne disease reports from different industrialized countries indicates that milk and milk products are implicated in 1-5 percent of the total bacterial foodborne outbreaks, with 39.1 percent attributed to milk, 53.1 percent to cheese, and 7.8 percent to other milk products.

Whereas milk quality and safety has been the topic of many research studies, raw milk still continues to be an issue for debate, which is primarily held on the internet where often non-scientifically based information circulates. Therefore, the aim of this study is to evaluate the risks and benefits related to the consumption of raw cow milk at one hand, and to evaluate the effect of heat treatments of milk on these risks and benefits on the other hand, considering the microbiological as well as the nutritional (health) aspects.

Conclusions
-----------
In this evaluation it is clearly demonstrated that the consumption of raw milk poses a realistic and unnecessary health threat because of its possible contamination with pathogenic bacteria. It is therefore recommended to heat [raw] milk before consumption, especially when served to young children, pregnant women, or any person suffering from a chronic disease or a suppressed immune system. In this context the attention is drawn to raw milk provided on farms to the general public (such as during a school visit) and raw milk distributors allowing the automatic supply of raw milk from a bulk reservoir to the consumer. >From a nutritional point of view, infants should only be given "infant formula" since unprocessed milk does not fulfill the nutritional needs of this age group.

Historical data show that the pasteurization of milk has led to improved public health and more recent data on occasional raw milk consumption indicate the hazard of bacterial infections, which could be avoided by a heat treatment. At present, thermal treatment remains the most frequently used and most effective method to increase the microbiological safety of milk without substantially changing the nutritional value of milk or other benefits associated with raw milk consumption. Table 4 [see original URL above] summarizes the main (claimed) benefits of raw milk consumption and the (claimed) detrimental effects of heating discussed in the present paper. Almost all arguments put forward by raw milk proponents for not heating milk, can be refuted, and the only substantial disadvantage of heating is the change in the organoleptic profile [taste] of milk. It is clear that this 'detrimental' effect of heating does not countervail the risk posed by raw milk consumption, namely of a milk-borne pathogen infection, which can have serious health consequences." - ProMed Mod.LL]

[A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/promed/p/38705>.]
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