Management of low-grade cervical cytology in young women. Cohort study from Denmark

OBJECTIVE

Cytology findings of atypical squamous cells of unknown significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL) are common among women under 30, but evidence on best management strategy is insufficient. We therefore investigated how different management strategies used in Denmark influenced biopsy rates and detection of cervical intraepithelial neoplasia (CIN).

METHODS

Register-based cohort study including Danish women aged less than 30 years and born 1980-95, with ASCUS/LSIL as their first abnormal cervical cytology in 2008-16. Rates and relative risks (RR) of biopsy and detection of CIN3+, CIN2 and < CIN2 during two years follow-up were compared between women referred directly to colposcopy after ASCUS/LSIL or undergoing additional testing, including mRNA or DNA test for high risk HPV or repeat cytology.

RESULTS

19,946 women with ASCUS and 19,825 with LSIL were included in the study of whom 92% had adequate information about follow-up. Among women referred directly to biopsy, CIN3+ was detected among 21%, CIN2 in 17%, while 62% had < CIN2. Repeating cytology after 6 months reduced the biopsy rate to 44% of which 53% had < CIN2. Biopsy rates with HPV test were 67% for DNA test, 77% with 14-type mRNA test and 58% with 5-type mRNA test. The detection of CIN3+ was somewhat higher, between 13% and 14% for the three HPV tests vs. 11% with repeat cytology. However, the detection of < CIN2 (not indicating treatment) also increased with RR 2.11 (95% CI 2.01-2.21) for 14-type mRNA test, 1.35 (95% CI 1.29-1.41) for 5-type mRNA test, and 1.86 (95% CI 1.76-1.97) with HPV DNA test.

CONCLUSIONS

The choice of management strategy influences both the detection rate for severe lesions (CIN3+) and the proportion of women followed up for potentially insignificant findings.

Histological outcomes in HPV-screened elderly women in Denmark

Introduction

Danish women exit cervical cancer screening at age 65 years, but 23% of cervical cancer cases occur beyond this age. In addition, due to gradual implementation of cervical cancer screening, older women are underscreened by today´s standards. A one-time screening with HPV test was therefore offered to Danish women born before 1948.

Methods

Register based study reporting histology diagnoses and conizations in women found HPV positive in the one-time screening. Number and proportion of women with severe or non-severe histology results were calculated for screened and HPV-positive women by age group or region of residence. Number of women with biopsy and/or conization per case of cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+) or CIN3+ were also calculated by age groups and region.

Results

4,479 (4.1% of screened women) had positive HPV test. 94% of these had one or more additional tests. 2,785 (62%) of HPV-positive women had histology results, and conization was performed in 1,076 (24% of HPV-positive and 1% of all screened women). HPV positivity and CIN3+ detection varied little between regions, but the proportions of HPV positive women undergoing histology varied between regions from 40% to 86% and the proportion with conization from 13% to 36%. Correspondingly, the number of histologies and conizations per CIN3+ detected varied from 5.9 to 11.2 and 1.8 to 4.7, respectively. In total, 514 CIN2+ (0.47% of screened women, 11% of HPV-positive) and 337 CIN3+ (0.31% of screened women, 7.5% of HPV-positive) were diagnosed, including 37 cervical cancer cases.

Discussion

HPV screening of insufficiently screened birth cohorts can potentially prevent morbidity and mortality from cervical cancer but longer follow-up is needed to see if cancer incidence declines in the screened women in the coming years. Management strategies differed among regions which influenced the proportions undergoing biopsy/conization.

Geography of COVID-19 in Denmark

Aim: To investigate the COVID-19 situation across geographical areas of Denmark over time. Methods: We used COVID-19 data from the Danish State Serum Institute on national, regional and municipality level. Cumulative number of tests, incidence, hospitalizations and deaths per 100,000 inhabitants were analysed for the five Danish regions and for all of Denmark. The cumulative number of tested and incidence of COVID-19 per 100,000 was compared for the two municipalities, Lolland and Gentofte. A sensitivity analysis of the COVID-19 indicators on a regional level was performed using number of tested as the denominator. Results: The Capital Region ranked highest on all analysed COVID-19 indicators with 10,849 tested, 365 cases, 63 hospitalized and 18 deaths per 100,000 by 2 June 2020. The three regions in western Denmark all had low levels, while Region Zealand ranked second highest. Despite general low health status in Lolland municipality, the cumulative incidence of COVID-19 was consistently below that of Gentofte. Sensitivity analysis showed that the Capital Region had the highest number of COVID-19 cases per 100,000 tested, but Region Zealand had a higher number of hospitalized and similar number of deaths per 100,000 tested as the Capital Region over time. Conclusion: COVID-19 had affected eastern Denmark, especially the Capital Region, considerably more than western Denmark. The difference may relate to population density and housing conditions.

Selection and Interpretation of Scientific Evidence in Preparation for Policy Decisions: A Case Study Regarding Introduction of Rotavirus Vaccine Into National Immunization Programs in Sweden, Norway, Finland, and Denmark

The World Health Organization recommends inclusion of rotavirus vaccines in national immunization programs (NIPs) worldwide. Nordic countries are usually considered comparable in terms of demographics and health-care services and have comparable rotavirus disease burden. Nevertheless, the countries have reached different decisions regarding rotavirus vaccine: Norway and Finland have already introduced rotavirus vaccines into their NIPs and Sweden is currently changing its recommendation and vaccines will now be introduced on a national scale while Denmark has decided against it. This study focuses on the selection and interpretation of medical and epidemiological evidence used during the decision-making processes in Sweden, Norway, Finland, and Denmark. The so-called "severity criteria" is identified as one of the main reasons for the different policy decisions reached across the Nordic countries.

Mumps resurgence in Denmark

BACKGROUND

The past decade has witnessed a resurgence of parotitisvirus (mumps) in several countries where seemingly good mumps control otherwise had been achieved through vaccination. Recently detection of mumps has increased in Denmark.

OBJECTIVES

To describe the age-specific changes and time trends of parotitisvirus detection in Denmark over a 10 year period.

STUDY DESIGN

Retrospective cohort study based on national laboratory data for parotitisvirus typing surveillance and national epidemiology data for mumps reporting.

RESULTS

The parotitisvirus detection rate has increased almost 10 times during the past 10 years from an incidence <0.1 per 100,000 in 2003 to 0.96 per 100,000 in 2013. The age distribution has shifted from children to young adults, and most cases are unvaccinated (54%) or vaccinated once (41%). The increase is due mainly to the existence of cohorts with low MMR vaccine coverage.

CONCLUSION

Analysis of mumps surveillance data from Denmark documents that the incidence of mumps is increasing, and that the resurgence of parotitisvirus is primarily occurring among young Danish adults. Almost half of the infected clinical mumps cases had received the first dose of MMR.

Incidence and Prognostic Factors for Legionnaires' Disease in Denmark 1993–2006

Objectives. To describe the incidence of Legionnaires’ disease and factors affecting survival in Denmark from 1993 to 2006. Methods. Retrospective register study using data on episodes of Legionnaires’ disease from notification forms and the National Reference Laboratory, and information on comorbidity from national registers on discharge diagnoses and mortality. Results. The average annual incidence of laboratory confirmed cases was 1.5 per 100000 people. The 30-day case fatality was 19%, ranging from 7% in travellers to 37% in hospital-acquired cases. Patients older than 60 years and patients with underlying disease were more likely-to die, as were patients infected with L. pneumophila serogroup 6. The lowest mortality was seen for L. pneumophila serogroup 1. Conclusion. Increased awareness of the disease, better diagnostics, and appropriate testing and treatment strategies are needed to improve survival. In particular, we focus on the relevance of diagnostic methods, such as polymerase chain reaction (PCR), that detect other serogroups than the urinary antigen tests used that will only reliably detect antigen from L. pneumophila serogroup 1. PCR is faster and more sensitive than culture.

[Gastrointestinal symptoms predominant in refugee children with malaria]

We present three cases of malaria in refugee children newly arrived from Sub-saharan Africa. Only one of the three children had fever and all had high parasite loads (2,5-14% parasitemia). Malaria is an important differential diagnosis in refugees from endemic areas, regardless of whether they present with fever.

[Listerial meningitis at the Department of Infectious Diseases, Copenhagen University Hospital 1983-2006]

INTRODUCTION

Listeria monocytogenes rarely causes meningitis, but when it does the course can be severe and case fatality rates high. The article describes clinical and laboratory findings as well as treatment and outcome among patients treated for listerial meningitis at the Department of Infectious diseases, Rigshospitalet from 1983-2006.

MATERIAL AND METHODS

Patient records were reviewed for all adults with a diagnosis of listerial meningitis.

RESULTS

A total of 40 patients with a discharge diagnosis of listerial meningitis were identified; records for 36 of these were available. 61% were men and 72% were older than 50 years. 64% had underlying, predisposing illnesses or took immunosuppressant medication. At presentation, patients had fever, neck stiffness, headache and/or change in mental status. The cerebrospinal fluid (CSF) cell count was raised in all patients, but the number and differential count of leukocytes in the CSF varied. L monocytogenes was present in blood and/or CSF from all patients. Treatment records were available for 35 patients, all of whom received ampicillin. Four patients died; they all had underlying diseases and three were older than 50 years.

CONCLUSION

The present study confirms the findings of other studies showing that listerial meningitis is more common in patients with underlying conditions, immunosuppression or age above 50. The case fatality rate is lower than that found in other reports, which could be due to the selection of patients. Listeriosis is an important differential diagnosis in predisposed individuals.

Outbreak of Clostridium difficile 027 in North Zealand, Denmark, 2008-2009

We report an outbreak of Clostridium difficile PCR ribotype 027 in Denmark. The outbreak includes to date 73 cases from the area north of Copenhagen, but there may be related cases elsewhere in Zealand. Most infections are healthcare-associated and in patients who previously received antibiotic treatment. The strain is resistant to moxifloxacin, erythromycin, and clindamycin, and carries genes for toxin A, toxin B, and for the binary toxin. The antimicrobial pattern differs from that of the strain involved in a small cluster in Denmark in 2006-2007. Because of this outbreak, hygienic measures in the involved hospitals have been reinforced. Nationwide, microbiological laboratories were alerted to the outbreak and encouraged to send isolates for toxin profiling and PCR ribotyping.

Outbreak of Clostridium difficile 027 in North Zealand, Denmark, 2008-2009

We report an outbreak of Clostridium difficile PCR ribotype 027 in Denmark. The outbreak includes to date 73 cases from the area north of Copenhagen, but there may be related cases elsewhere in Zealand. Most infections are healthcare-associated and in patients who previously received antibiotic treatment. The strain is resistant to moxifloxacin, erythromycin, and clindamycin, and carries genes for toxin A, toxin B, and for the binary toxin. The antimicrobial pattern differs from that of the strain involved in a small cluster in Denmark in 2006-2007. Because of this outbreak, hygienic measures in the involved hospitals have been reinforced. Nationwide, microbiological laboratories were alerted to the outbreak and encouraged to send isolates for toxin profiling and PCR ribotyping.