M Kuusi

National Institute for Health and Welfare, Finland, Helsinki, Southern Finland Province, Finland

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Publications (61)198.84 Total impact

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    ABSTRACT: Abstract Francisella tularensis is a highly virulent intracellular bacterium causing the zoonotic disease tularemia. It recurrently causes human and animal outbreaks in northern Europe, including Finland. Although F. tularensis infects several mammal species, only rodents and lagomorphs seem to have importance in its ecology. Peak densities of rodent populations may trigger tularemia outbreaks in humans; however, it is still unclear to which extent rodents or other small mammals maintain F. tularensis in nature. The main objective of this study was to obtain information about the occurrence of F. tularensis in small mammals in Finland. We snap-trapped 547 wild small mammals representing 11 species at 14 locations around Finland during 6 years and screened them for the presence of F. tularensis DNA using PCR analysis. High copy number of F. tularensis-specific DNA was detected in tissue samples of five field voles (Microtus agrestis) originating from one location and 2 years. According to DNA sequences of the bacterial 23S ribosomal RNA gene amplified from F. tularensis-infected voles, the infecting agent belongs to the subspecies holarctica. To find out the optimal tissue for tularemia screening in voles, we compared the amounts of F. tularensis DNA in lungs, liver, spleen, and kidney of the infected animals. F. tularensis DNA was detectable in high levels in all four organs except for one animal, whose kidney was F. tularensis DNA-negative. Thus, at least liver, lung, and spleen seem suitable for F. tularensis screening in voles. Thus, liver, lung, and spleen all seem suitable for F. tularensis screening in voles. In conclusion, field voles can be heavily infected with F. tularensis subsp. holarctica and thus potentially serve as the source of infection in humans and other mammals.
    Vector borne and zoonotic diseases (Larchmont, N.Y.) 02/2014; · 2.61 Impact Factor
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    ABSTRACT: SUMMARY In 2010, a marked increase in listeriosis incidence was observed in Finland. Listeria monocytogenes PFGE profile 96 was responsible for one-fifth of the reported cases and a cluster of PFGE profile 62 was also detected. Investigations revealed two fishery production plants with persistent Listeria contamination. It appears likely that the plants were at least partly responsible for the increase of listeriosis. Epidemiological investigation revealed that 57% (31/54) of cases with underlying immunosuppressive condition or medication reported eating gravad or cold-smoked fish. Two public notices were issued by THL and Evira informing which groups were most at risk from the effects of listeriosis and should therefore be cautious in consuming certain products. Systematic sampling of foods and adequate epidemiological investigation methods are required to identify the sources of Listeria infections. Continuous control measures at fishery production plants producing risk products are essential.
    Epidemiology and Infection 01/2014; · 2.87 Impact Factor
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    ABSTRACT: 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.
    PLoS ONE 01/2014; 9(1):e85457. · 3.73 Impact Factor
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    ABSTRACT: SUMMARY Few population-based data are available on factors associated with pneumonic and ulceroglandular type B tularaemia. We conducted a case-control study during a large epidemic in 2000. Laboratory-confirmed case patients were identified through active surveillance and matched control subjects (age, sex, residency) from the national population information system. Data were collected using a self-administered questionnaire. A conditional logistic regression model addressing missing data with Bayesian full-likelihood modelling included 227 case patients and 415 control subjects; reported mosquito bites [adjusted odds ratio (aOR) 9·2, 95% confidence interval (CI) 4·4-22, population-attributable risk (PAR) 82%] and farming activities (aOR 4·3, 95% CI 2·5-7·2, PAR 32%) were independently associated with ulceroglandular tularaemia, whereas exposure to hay dust (aOR 6·6, 95% CI 1·9-25·4, PAR 48%) was associated with pneumonic tularaemia. Although the bulk of tularaemia type B disease burden is attributable to mosquito bites, risk factors for ulceroglandular and pneumonic forms of tularaemia are different, enabling targeting of prevention efforts accordingly.
    Epidemiology and Infection 12/2013; · 2.87 Impact Factor
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    ABSTRACT: 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.
    Scandinavian Journal of Public Health 05/2013; · 1.97 Impact Factor
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    ABSTRACT: Aims: In November through December 2007, the drinking water distribution system in the town of Nokia, Finland, was contaminated with treated sewage effluent that resulted in a large gastroenteritis outbreak in the community. The aim of the present study was to investigate if the contaminated water in this outbreak was also a potential source of Clostridium difficile infections. Methods: Samples from the contaminated tap water and treated sewage effluent were collected. Stool samples from a portion of patients that fell ill during the outbreak were examined for C. difficile. PCR ribotyping was performed on toxin positive C. difficile isolates and the genetic profiles of the water and patient isolates were compared. Results: Twelve toxin-positive C. difficile isolates were found in water samples: five from contaminated tap water and seven from treated sewage effluent. Among these, four and five distinct PCR ribotype profiles were identified, respectively. Four PCR ribotype profiles were found among nine human faecal C. difficile isolates. Two isolates, one from tap water and one from a patient, had an indistinguishable PCR ribotype profile. Conclusions: Our findings demonstrate for the first time C. difficile contamination of a tap water distribution system and waterborne transmission of toxigenic C. difficile seems possible.
    Scandinavian Journal of Public Health 03/2013; · 1.97 Impact Factor
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    ABSTRACT: We describe the first verified domestic HEV case in a previously healthy 53-year-old man who presented a three-day history of upper stomach pain, nausea, fever, arthralgia and fatigue. At the first phase laboratory tests revealed high levels of AST and ALT and at the second phase high levels of bilirubin. Serum was positive for anti-HEV IgM and for HEV RNA confirming the diagnosis of acute hepatitis E. The HEV was genotype 3. Jaundice resolved in three months. In nonendemic areas autochthonous hepatitis E is more common than previously recognized and is possible in patients with acute hepatitis.
    Duodecim; lääketieteellinen aikakauskirja 01/2013; 129(20):2169-73.
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    ABSTRACT: SUMMARY As a major foodborne pathogen, Campylobacter is frequently isolated from food sources of animal origin. In contrast, human Campylobacter illness is relatively rare, but has a considerable health burden due to acute enteric illness as well as severe sequelae. To study silent transmission, serum antibodies can be used as biomarkers to estimate seroconversion rates, as a proxy for infection pressure. This novel approach to serology shows that infections are much more common than disease, possibly because most infections remain asymptomatic. This study used antibody titres measured in serum samples collected from healthy subjects selected randomly in the general population from several countries in the European Union (EU). Estimates of seroconversion rates to Campylobacter were calculated for seven countries: Romania, Poland, Italy, France, Finland, Denmark and The Netherlands. Results indicate high infection pressures in all these countries, slightly increasing in Eastern EU countries. Of these countries, the differences in rates of notified illnesses are much greater, with low numbers in France and Poland, possibly indicating lower probability of detection due to differences in the notification systems, but in the latter case it cannot be excluded that more frequent exposure confers better protection due to acquired immunity.
    Epidemiology and Infection 12/2012; · 2.87 Impact Factor
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    ABSTRACT: SUMMARY Mosquito-borne Sindbis virus (SINV) causes rash-arthritis syndrome in Finland. Major outbreaks with approximately 7-year cycles have caused substantial burden of illness. Forest dwelling grouse are suspected to be amplifying hosts, with the infection transmitted to humans by mosquito bites. SINV infection surveillance data for 1984-2010 were used to create a negative binomial hurdle model, with seasonality, long-term cycles, climatic, ecological and socioeconomic variables. Climatic factors during early summer and amount of snow in April described the occurrence and incidence of SINV infections. Regulated water shore and hatch-year black grouse density described the occurrence, while population working in agriculture, agricultural land (negative) and income (negative) described the incidence of the disease. The prediction for 2009 was 85 cases (95% prediction interval 2-1187), while the actual occurrence was 106. We identified novel and known risk factors. The prevention of SINV infections in regulated water areas by infected mosquito populations should be targeted.
    Epidemiology and Infection 11/2012; · 2.87 Impact Factor
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    ABSTRACT: SUMMARY In 2010, 7/44 (16%) reported foodborne outbreaks in Finland were linked with raw beetroot consumption. We reviewed data from the national outbreak registry in order to hypothesize the aetiology of illness and to prevent further outbreaks. In the seven outbreaks, 124 cases among 623 respondents were identified. Consumption of raw beetroot was strongly associated with gastrointestinal illness (relative risk 8·99, 95% confidence interval 6·06-13·35). The illness was characterized by sudden onset of gastrointestinal symptoms; the median incubation time was 40 min and duration of illness 5 h. No common foodborne pathogens or toxins were found in either clinical or beetroot samples, but all tested beetroot samples were of poor quality according to total bacterial counts. Beta-haemolytic Pseudomonas fluorescens was detected in several beetroot samples but its effect on human health is unknown. No outbreaks were reported after the Finnish Food Safety Authority Evira advised against serving raw beetroot in institutional canteens.
    Epidemiology and Infection 10/2012; · 2.87 Impact Factor
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    ABSTRACT: BACKGROUND: Y. enterocolitica biotype (BT) 1A strains are often isolated from human clinical samples but their contribution to disease has remained a controversial topic. Variation and the population structure among the clinical Y. enterocolitica BT 1A isolates have been poorly characterized. We used multi-locus sequence typing (MLST), 16S rRNA gene sequencing, PCR for ystA and ystB, lipopolysaccharide analysis, phage typing, human serum complement killing assay and analysis of the symptoms of the patients to characterize 298 clinical Y. enterocolitica BT 1A isolates in order to evaluate their relatedness and pathogenic potential. RESULTS: A subset of 71 BT 1A strains, selected based on their varying LPS patterns, were subjected to detailed genetic analyses. The MLST on seven house-keeping genes (adk, argA, aroA, glnA, gyrB, thrA, trpE) conducted on 43 of the strains discriminated them into 39 MLST-types. By Bayesian analysis of the population structure (BAPS) the strains clustered conclusively into two distinct lineages, i.e. Genetic groups 1 and 2. The strains of Genetic group 1 were more closely related (97% similarity) to the pathogenic bio/serotype 4/O:3 strains than Genetic group 2 strains (95% similarity). Further comparison of the 16S rRNA genes of the BT 1A strains indicated that altogether 17 of the 71 strains belong to Genetic group 2. On the 16S rRNA analysis, these 17 strains were only 98% similar to the previously identified subspecies of Y. enterocolitica. The strains of Genetic group 2 were uniform in their pathogenecity-related properties: they lacked the ystB gene, belonged to the same LPS subtype or were of rough type, were all resistant to the five tested yersiniophages, were largely resistant to serum complement and did not ferment fucose. The 54 strains in Genetic group 1 showed much more variation in these properties. The most commonly detected LPS types were similar to the LPS types of reference strains with serotypes O:6,30 and O:6,31 (37%), O:7,8 (19%) and O:5 (15%). CONCLUSIONS: The results of the present study strengthen the assertion that strains classified as Y. enterocolitica BT 1A represent more than one subspecies. Especially the BT 1A strains in our Genetic group 2 commonly showed resistance to human serum complement killing, which may indicate pathogenic potential for these strains. However, their virulence mechanisms remain unknown.
    BMC Microbiology 09/2012; 12(1):208. · 3.10 Impact Factor
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    ABSTRACT: BACKGROUND: Published incidence rates of human salmonella infections are mostly based on numbers of stool culture-confirmed cases reported to public health surveillance. These cases constitute only a small fraction of all cases occurring in the community. The extend of underascertainment is influenced by health care seeking behaviour and sensitivity of surveillance systems, so that reported incidence rates from different countries are not comparable. We performed serological cross-sectional studies to compare infection risks in eight European countries independent of underascertainment. METHODS: A total of 6,393 sera, mostly from existing serum collections representative of the adult population in Denmark, Finland, France, Italy, Poland, Romania, Sweden, and The Netherlands were analyzed. Immunoglobulin A (IgA), IgM, and IgG against salmonella lipopolysaccharides were measured by in-house mixed ELISA. We converted antibody concentrations to estimates of infection incidence ('sero-incidence') using a Bayesian backcalculation model, based on previously studied antibody decay profiles in persons with culture-confirmed salmonella infections. We compared sero-incidence with incidence of cases reported through routine public health surveillance and with published incidence estimates derived from infection risks in Swedish travellers to those countries. RESULTS: Sero-incidence of salmonella infections ranged from 56 (95% credible interval 8-151) infections per 1,000 person-years in Finland to 547 (343-813) in Poland. Depending on country, sero-incidence was approximately 100 to 2,000 times higher than incidence of culture-confirmed cases reported through routine surveillance, with a trend for an inverse correlation. Sero-incidence was significantly correlated with incidence estimated from infection risks in Swedish travellers. CONCLUSIONS: Sero-incidence estimation is a new method to estimate and compare the incidence of salmonella infections in human populations independent of surveillance artefacts. Our results confirm that comparison of reported incidence between countries can be grossly misleading, even within the European Union. Because sero-incidence includes asymptomatic infections, it is not a direct measure of burden of illness. But, pending further validation, it is a promising and cost-effective approach to assess infection risks and to evaluate the effectiveness of salmonella control programmes across countries.
    BMC Public Health 07/2012; 12(1):523. · 2.08 Impact Factor
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    ABSTRACT: Shiga toxin–producing Escherichia coli (STEC) is a pathogen that causes gastroenteritis and bloody diarrhea but can lead to severe disease, such as hemolytic uremic syndrome (HUS). STEC serotype O78:H– is rare among humans, and infections are often asymptomatic. We detected a sorbitol-fermenting STEC O78:H–:stx1c:hlyA in blood and fecal samples of a 2-week-old boy who had bacteremia and HUS and in fecal samples of his asymptomatic family members. The phenotypic and genotypic characteristics and the virulence properties of this invasive STEC were investigated. Our findings demonstrate that contrary to earlier suggestions, STEC under certain conditions can invade the human bloodstream. Moreover, this study highlights the need to implement appropriate diagnostic methods for identifying the whole spectrum of STEC strains associated with HUS.
    Emerging Infectious Diseases 04/2012; · 6.79 Impact Factor
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    ABSTRACT: 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. 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. 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. 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.
    Rheumatology (Oxford, England) 11/2011; 51(3):513-8. · 4.24 Impact Factor
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    ABSTRACT: 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.
    Apmis 11/2011; 119(11):735-40. · 2.07 Impact Factor
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    ABSTRACT: To assess the occurrence, clinical picture, and triggering infections of reactive arthritis (ReA) associated with a large waterborne gastroenteritis outbreak. After an extensive sewage contamination of the water supply system, an estimated 8453 of the 30 016 inhabitants of the town of Nokia fell ill. General practitioners and occupational physicians were advised to refer any patients with suspicion of new ReA to rheumatological examination including faecal culture, human leucocyte antigen (HLA)-B27 and antibody tests for Campylobacter, Salmonella, and Yersinia. Forty-five patients (33 females, 12 males) aged 16-77 years (median 53) were referred. ReA was diagnosed in 21, postinfectious arthralgia in 13, and other musculoskeletal conditions in 11 patients. HLA-B27 was positive in five out of 44 patients (11%). Of the 21 patients with ReA, possible triggering infections were observed in seven (33%), Campylobacter in four, Yersinia in three, and Salmonella in one, who also had Campylobacter infection. ReA was mild in all but one patient who presented with persistent Salmonella enterica serotype enteritidis infection. Taking into account the large population contaminated with potentially arthritogenic agents, the occurrence of ReA was rare and mild in character.
    Scandinavian journal of rheumatology 06/2011; 40(5):358-62. · 2.51 Impact Factor
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    ABSTRACT: A nationwide outbreak of Salmonella enterica serotypes Newport and Reading occurred between 17 October and 28 November 2008 in Finland. A total of 77 culture-confirmed Salmonella Newport and 30 Salmonella Reading cases, including one case with a double infection, were reported. All strains isolated from the patients were subtyped using serotyping, microbial resistance profiling, and pulsed-field gel electrophoresis (PFGE). Here, the PFGE patterns of the studied Salmonella Newport strains were identical, whereas four different PFGE profiles were found among the Salmonella Reading strains. Two elderly patients died within 2 weeks of the onset of symptoms. Three geographical clusters of cases with an epidemiological link were identified. The traceback investigation suggested that the factor connecting the cases was ready-chopped iceberg lettuce available for mass catering use. However, none of the tested food, environmental samples, or the samples taken from the staff of the processing plant contained Salmonella bacteria. Tracing back to outbreak sources with a short shelf life can be complex.
    Journal of food protection 06/2011; 74(6):1035-40. · 1.83 Impact Factor
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    ABSTRACT: 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.
    Zoonoses and Public Health 05/2011; 58(8):589-96. · 2.09 Impact Factor
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    ABSTRACT: In 2009, the number of foodborne norovirus outbreaks in Finland seemed markedly high, and many outbreaks seemed to be linked to imported frozen raspberries. We reviewed the data regarding all notified foodborne outbreaks in 2009 in Finland in order to assess the magnitude of the problem and to summarize the information on raspberry-linked outbreaks. Between March and August, 13 norovirus outbreaks affecting about 900 people could be linked to imported frozen raspberries. Two raspberry samples corresponding to two batches of raspberries were positive for norovirus. These two batches proved to have been the likely source in six of the 13 outbreaks. Analytical studies had not been conducted for six outbreaks, and virological test results were inconclusive in two. However, combining epidemiological and microbiological methods often enabled finding the source, as exemplified in investigation of a large school outbreak. To ensure prompt control measures in similar situations in the future, both aspects of outbreak investigations should be strengthened.
    Epidemiology and Infection 03/2011; 140(2):260-7. · 2.87 Impact Factor
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    ABSTRACT: We assessed the potential of multilocus variable-number tandem-repeat analysis (MLVA), pulsed-field gel electrophoresis (PFGE), and antimicrobial susceptibility testing for discriminating 104 sporadic and outbreak-related Yersinia enterocolitica (YE) bio/serotype 3-4/O:3 and 2/O:9 isolates. MLVA using six VNTR markers was performed in two separate multiplex PCRs, and the fluorescently labeled PCR products were accurately sized on an automated DNA sequencer. MLVA discriminated 82 sporadic YE 3-4/O:3 and 2/O:9 strains into 77 types, whereas PFGE with the restriction enzyme NotI discriminated the strains into 23 different PFGE pulsotypes. The discriminatory index for a sporadic strain was 0.862 for PFGE and 0.999 for MLVA. MLVA confirmed that a foodborne outbreak in the city of Kotka, Finland in 2003 had been caused by a multiresistant YE 4/O:3 strain that was distinctly different from those of epidemiologically unrelated strains with an identical PFGE pulsotype. The multiresistance of Y. enterocolitica strains (19% of the sporadic strains) correlated significantly (p = 0.002) with travel abroad. All of the multiresistant Y. enterocolitica strains belonged to four PFGE pulsotypes that did not contain any susceptible strains. Resistance to nalidixic acid was related to changes in codons 83 or 87 that stemmed from mutations in the gyrA gene. The conjugation experiments demonstrated that resistance to CHL, STR, and SUL was carried by a conjugative plasmid. MLVA using six loci had better discriminatory power than PFGE with the NotI enzyme. MLVA was also a less labor-intensive method than PFGE and the results were easier to analyze. The conjugation experiments demonstrated that a resistance plasmid can easily be transferred between Y. enterocolitica strains. Antimicrobial multiresistance of Y. enterocolitica strains was significantly associated with travel abroad.
    BMC Microbiology 02/2011; 11:42. · 3.10 Impact Factor

Publication Stats

550 Citations
198.84 Total Impact Points


  • 2009–2013
    • National Institute for Health and Welfare, Finland
      • • Epidemiologic Surveillance and Response Unit
      • • Bacteriology Unit
      Helsinki, Southern Finland Province, Finland
  • 2011
    • University of Tampere
      • Department of Internal Medicine
      Tampere, Western Finland, Finland
  • 2002–2006
    • National Public Health Institute
      Helsinki, Southern Finland Province, Finland
  • 2004
    • Helsinki University Central Hospital
      • Department of Medicine
      Helsinki, Province of Southern Finland, Finland
  • 2003
    • Norwegian Institute of Public Health
      • Division of Infectious Disease Control
      Kristiania (historical), Oslo County, Norway