Respiratory syncytial virus infection--risk factors for hospital admission: a case-control study.

UNLABELLED: Most infants are infected with respiratory syncytial virus (RSV) during the first 2 y of life. The majority have only a mild upper respiratory tract infection, but 1-2% develop a more severe illness and are admitted to hospital. AIM: To carry out a study of risk factors for hospital admission because of RSV infection in Denmark in children aged less than 2 y of age. METHODS: The study population included all 1252 children admitted to hospital with verified RSV infection in two Danish counties during the 5-y period 1990-1994. The investigation comprised a retrospective case-control study with five matched controls per case. In a multivariate analysis the risk factors included medical and demographic variables, and in infants <3 mo of age at hospitalization, two aspects of innate immunity: mannose-binding lectin (MBL) concentration and maternal RSV serum antibody titre, measured on eluates from stored dried blood from the infants' 4th day of life. The effect of each risk factor is expressed as an odds ratio, corresponding to the relative risk of being a case rather than a control if the risk factor is present. RESULTS: The following independent risk factors were identified: age, sex, month of birth, gestational age, birthweight, presence of a sibling, up to 5 y older than the case, and maternal smoking during pregnancy. There was a marginal effect of maternal RSV antibody levels, but no effect of neonatal serum MBL concentration or of crowding in the household. CONCLUSIONS: Ninety percent of cases and 80% of controls had one or more risk factors. Even though several factors were found to increase the risk for hospitalization for RSV disease, all the effects were small and no single specific factor could be identified to explain the hospitalization of the minority of children with RSV infection.

[Cases of measles in Denmark are caused by reintroduction of virus from abroad]. / Maeslingetilfaelde i Danmark skyldes gentagne introduktioner af virus fra udlandet.

Measles vaccination was implemented in the child vaccination programme in Denmark in 1987 and produced a rapid decline in the incidence. Few cases were recorded annually until 1999. The measles virus isolated in Denmark during 1997-1998 was compared by partial sequencing of the haemagglutinin-coding region with Danish strains from the prevaccination era collected in 1965-1983, as well as with representatives of globally circulating strains of today. The dissimilarity of the prevaccination era strains identified in Denmark in 1997-1998 along with the similarity of these five strains with globally circulating strains at present, substantiate the conclusion that there is no persistent circulation of the measles virus in Denmark.

Chlamydia pneumoniae and possible relationship to asthma. Serum immunoglobulins and histamine release in patients and controls.

Chlamydia pneumoniae (C.pn.) is claimed to be of importance for the development of bronchial asthma in previously healthy individuals. This is a new and speculative theory. Earlier studies have mainly focused on C.pn. and exacerbation of asthma. If this new theory were true, one would expect titres of C.pn.-specific IgG to be higher or more common in patients compared with controls. It would also seem probable that pathobiological mechanisms as found in connection with other microorganisms could be demonstrated, i.e. presence of C.pn.-specific IgE and the capability of C.pn. to induce or enhance histamine release from basophil leukocytes. We therefore examined C.pn.-specific IgE, IgG and IgM in sera from 22 adults with bronchial asthma and 25 healthy controls. IgE was verified by passive sensitization of basophils from umbilical cord blood. The prevalence of IgE was approx. 69% and IgG approx. 23% in both groups. IgG-titres were between 1:16 and 1:64 in both groups. No IgM was found. Further, C.pn. could neither induce nor enhance histamine release from basophil leukocytes of patients or controls. We conclude that patients with bronchial asthma and healthy controls do not differ in relation to 1) C.pn.-specific IgE in sera, 2) the capability of C.pn. to induce or enhance histamine release from basophil leukocytes, since no such effect was found, or 3) previous C.pn. infection judged by the presence of specific IgG antibodies. Our results cannot support the theory that C.pn. is a cause of adult-onset asthma.

Secretory IgM and IgA antibodies to respiratory syncytial virus in nasopharyngeal aspirates: a diagnostic supplement to antigen detection.

BACKGROUND: RSV-shedding during an RSV-infection declines dramatically after the first week of infection. It could be of interest to be able to diagnose RSV-infection for a longer period of time by detection of specific RSV-IgM and RSV-IgA in nasopharyngeal aspirates (NPA) in order to minimize unnecessary antibiotics. OBJECTIVES: To evaluate an ELISA to detect specific RSV-IgM and RSV-IgA in NPA as a supplement to RSV-antigen detection. STUDY DESIGN: A total of 104 NPA from 101 children (median age 9 months) with acute respiratory disease (group 1) admitted to hospital and consecutive NPA (collected on day 0, 7, 14, 30 and 60) from 11 children (median age 3 months) with a proven RSV infection (group 2) were collected. All NPA from group 1 were analysed for RSV-antigen, RSV-IgM and RSV-IgA. NPA from group 2 were analysed for RSV-IgM and RSV-IgA. RESULTS: Thirty-five NPA in group 1 were positive for RSV-antigen and 64 were positive for RSV-antigen test alone found 44% and the RSV-IgM test alone found 80%. In group 2 8/11 (73%) has an excellent RSV-IgM response day 7, the rest responded later. Only 5/11 (46%) had a less pronounced RSV-IgA response on day 7, three cases responded later and three did not respond at all. RSV-IgM disappeared in 8/11 (73%) and RSV-IgA in 7/8 (88%) between day 30-60. CONCLUSIONS: Specific RSV-IgM is a valuable supplement to RSV-antigen detection for the diagnosis of acute and recent RSV infection.

In vivo cell-mediated immunity and vaccination response following prolonged, intense exercise.

Epidemiological and experimental studies have shown increased frequency and severity of infections after intense, long-term exercise. This study examines whether an in vivo impairment of the cell-mediated immunity and antibody production can be demonstrated after intense, long-term exercise. Twenty-two male triathletes performed one-half an ironman (group A). Vaccinations with tetanus and diphtheritis toxoid and purified pneumococcal polysaccharide were given after the exercise. Furthermore, a skin test with seven different antigens was applied on the forearm. Antibody titers were measured before and 2 wk after the exercise. The skin test was read 48 h after the application. Eleven non-exercising triathletes (group B) and 22 moderately trained men (group C) were used as control groups. Group A revealed a significantly lower skin test response to the tetanus antigen than both groups B and C. In group A, a smaller cumulative response (sum of the diameters of indurations and number of positive skin test spots) was found than in both groups B and C. No differences in antibody titers were found among the three groups. Thus, the in vivo cell-mediated immunity was impaired in the first days after prolonged, high intensity exercise, whereas there was no impairment of the in vivo antibody production measured 2 wk after vaccination.

Monoclonal antibodies for the rapid diagnosis of influenza-B virus infections by ELISA: production and characterization.

BACKGROUND: Monoclonal antibodies directed against conserved epitopes of viral proteins have substantially improved the accuracy of several immunochemical methods in diagnostic virology. OBJECTIVES: To characterize mouse monoclonal antibodies directed against structural protein antigens of influenza-B virus and evaluate their use as diagnostic reagents for the direct detection of such antigens in clinical specimens from patients with respiratory infections of unknown aetiology. STUDY DESIGN: (a) Production and characterization of monoclonal antibodies against influenza-B viral antigens, and (b) their use in two different ELISA systems for detecting influenza-B antigen either directly in clinical specimens or after confirmation by rapid culture in MDCK cells. RESULTS: Four monoclonal antibodies were selected for their specificity for the nucleoprotein antigen as demonstrated by Western blot analysis. The specificity of these antibodies for different epitopes of the nucleoprotein was demonstrated by competition experiments, using unlabelled and biotin-labelled purified antibodies in a sandwich assay. All four antibodies belong to the mouse IgG(2a) isotype, lack haemagglutination inhibition and neutralization properties and exhibit titres as high as 10(-6) in ELISA with as little as 30 ng purified influenza-B virus. ELISA methods using these antibodies detected only influenza-B viral antigens in direct testing of clinical specimens from patients with known influenza-B or influenza-A infections, or after reisolating virus from such specimens in tissue culture of MDCK cells. CONCLUSION: The antibodies were suitable for the direct detection and typing of influenza-B virus in clinical specimens or for use in rapid confirmation cultures.

Evaluation of Abbott TestPack RSV and an in-house RSV ELISA for detection of respiratory syncytial virus in respiratory tract aspirates.

The Abbott TestPack RSV was compared with an in-house RSV enzyme-linked immunosorbent assay (ELISA) for detection of respiratory syncytial virus (RSV) antigen. Nasopharyngeal specimens were obtained from 121 inpatients. RSV antigen was detected in 46 specimens by the Abbott TestPack, 42 of these being confirmed by the in-house RSV ELISA. Of the 75 specimens tested negative in the Abbott TestPack RSV, one was found positive by the in-house RSV ELISA. The sensitivity and specificity of the Abbott TestPack RSV versus the RSV ELISA were 98% and 95% respectively.

Monoclonal antibodies for the direct detection of influenza-A virus by ELISA in clinical specimens from patients with respiratory infections.

BACKGROUND: Monoclonal antibody technology provides antibody reagents of known specificity, high titres and unlimited availability, that form ideal reference antibodies for use in specific viral antigen-detection methods. OBJECTIVES: To produce mouse monoclonal antibodies against antigenic sites of influenza-A virus, and evaluate their use as diagnostic reagents in a sandwich ELISA. STUDY DESIGN: (1) Production and characterization of monoclonal antibodies against influenza-A virus; (2) application of these antibodies in an ELISA method for direct antigen detection; and (3) evaluation of the ELISA as routine procedure. RESULTS: Four monoclonal antibodies (A1-A4) from mice immunized intranasally with influenza-A virus were selected according to their specific reactivity with either nucleoprotein or matrix protein antigens as demonstrated by Western blot analysis. These antibodies lacked haemagglutination inhibition and neutralization properties and recognized both H1N1 and H3N2 strains of influenza-A virus equally. A sandwich ELISA using unlabelled antibodies for antigen capture and biotin-labelled antibodies for antigen detection was used to analyse nasopharyngeal secretions or nasal swabs from culture-confirmed influenza-A-infected patients and comparable specimens from patients with other viral respiratory infections. Only influenza-A virus (strains H1N1 and H3N2) could be detected in samples from patients with known influenza-A and influenza-B infections, and also after re-isolation of such viruses in conventional cultures of MDCK cells or embryonated hens' eggs. The antigen-detection assay showed a diagnostic sensitivity of 100% and a specificity of 98.3% compared with conventional culture methods. CONCLUSION: The reported ELISA appears to be a rapid and inexpensive method for diagnosis and epidemiological studies of influenza-A infections.

Trials of Edmonston-Zagreb measles vaccine in Guinea-Bissau: serological responses following vaccination with Edmonston-Zagreb strain at 4-8 months versus vaccination with Schwarz strain at 9-12 months of age.

In two trials of measles vaccination in Guinea-Bissau, children were randomized to receive either the Edmonston-Zagreb (EZ) virus at age 4-8 months or, as a control group, a standard dose (5000 p.f.u.) of the Schwarz (SW) virus at 9-12 months. In the first trial a medium dose of EZ virus (40,000 p.f.u.) was used and in the later trial a high dose (150,000 p.f.u.). Pre- and postvaccination blood samples were analysed with a haemagglutination inhibition (HAI) test and an enzyme-linked immunosorbent assay (ELISA). For the ELISA the blood samples were collected on filter paper. Of 362 prevaccination specimens, 18 and 55%, respectively, were positive in the ELISA and HAI tests. At 18-20 months, the children who had received the EZ vaccine had a seropositivity of 91% by the ELISA method and one of 89% by the HAI method. The equivalent values for the SW group of children were 100 and 96% respectively. Antibody levels in the EZ group, as measured by either method, were significantly lower than the levels in the SW group. The serological results of the present study suggest that lowering the age at measles vaccination to below 9 months is feasible. However, further studies are needed to determine which virus strain, dosage and age at vaccination will prove to be optimal in countries where severe measles is common before the age of 9 months.

The humoral immune response to Chlamydia trachomatis in patients with acute reactive arthritis.

Sera from 25 patients with clinical signs of reactive arthritis were analysed for antibodies against Chlamydia trachomatis by immunoblotting. Purified elementary bodies, purified Chlamydia outer membrane complexes, and purified recombinant subcomponents were used as antigens. Antibodies against C. trachomatis cysteine rich outer membrane protein 2 (Omp2) and lipopolysaccharide (LPS) were detected in 10 patients. Thus 40% of the patients presented antibodies specific for C. trachomatis. There was no correlation between acute reactive arthritis and antibodies to heat-shock proteins GroEL, GroES and DnaK.

Relationship between viral antibodies and bronchial hyperresponsiveness in 495 unselected children and adolescents.

The purpose of this study was to investigate whether recent and previous subclinical viral respiratory infection can explain the presence of increased bronchial responsiveness to histamine. We studied a randomly selected population of 495 children and adolescents, aged 7-16 years, from Copenhagen. If the subjects had had symptoms of respiratory infection recently, the examination was postponed for at least 6 weeks. Bronchial hyperresponsiveness (BHR) to inhaled histamine was found in 79 (16%) of the subjects, of whom 28 had asthma. Forty-eight subjects (10%) had increased levels of serum IgM antibodies against either parainfluenza, influenza, adenovirus, or respiratory syncytial virus (RSV), reflecting a recently acquired infection. No association between BHR and antibodies against respiratory viruses was found, as 7 (8.9%) of the 79 subjects with BHR and 41 (9.9%) of the 416 subjects without BHR had viral antibodies. Furthermore, no association between degree of bronchial responsiveness and viral antibodies was found. Moreover, 251 individuals (51%) had signs of earlier RSV infection, i.e. IgG antibodies against RSV. No relationship was found between age of the subjects and the presence of antibodies against either respiratory viruses in general or IgG-RSV. No relationship was found between the presence of antibodies against RSV and BHR; furthermore, evidence of earlier RSV infection was unrelated to the level of lung function and degree of bronchial responsiveness. We conclude that increased bronchial responsiveness in asymptomatic, unselected schoolchildren and adolescents is not likely to be caused by recent or previous viral respiratory infections.

Outbreak of Chlamydia pneumoniae infection in four farm families.

The epidemiology of Chlamydia pneumoniae infection was studied in an outbreak in four farm families living close together in Denmark. Eleven of 20 members of the families studied had bronchitis or pneumonia characteristic of Chlamydia pneumoniae infection. Serologic evidence of Chlamydia pneumoniae as causative agent was strengthened by a high incidence of epidemic infection. Transmission within families and a high frequency of disease versus asymptomatic infection are two findings which deviate from epidemiological patterns of Chlamydia pneumoniae infection as currently known.

Assessment of risk of microbial contamination by use of multidose containers of injectable products.

At a vaccination centre 200 emptied multidose vials were tested for sterility. All vials had contained 10 doses of a vaccine without added preservative. None of the 200 vials was culture-positive. The vaccine did not comply with the pharmacological test for effectiveness of antimicrobial preservatives.

A new respiratory tract pathogen: Chlamydia pneumoniae strain TWAR.

Chlamydia pneumoniae strain TWAR, the new third species of Chlamydia, is a common cause of pneumonia and other acute respiratory tract infections. About 10% of hospitalized and outpatient pneumonia cases have been associated with TWAR infection. TWAR is among the four or five most commonly identified causes of all pneumonia. Most TWAR infections are mild or asymptomatic, but occasionally severe pneumonia with death has been observed. Laboratory diagnosis is not generally available. Vigorous treatment with tetracycline or erythromycin is recommended. Both epidemic and endemic infections have been described in North America and the Nordic Countries. Population prevalence antibody studies suggest that TWAR infection is wide-spread throughout the world, that nearly everyone is infected and reinfected during their life-time, and that infection is common in all ages except those less than 5 years in temperate zone countries. The infection is transmitted from person to person, apparently with a long incubation period.

Subclinical measles infection in vaccinated seropositive individuals in arctic Greenland.

Measles vaccination was performed in the arctic district of Scoresbysund, Greenland in 1968, which had never been exposed to natural measles. More than 90% of the total population was vaccinated and a 94-100% seroconversion was obtained. During a serological survey to examine the immunity status of the vaccinees, it was discovered that a temporary increase in measles antibodies took place in the majority of the population 2-4 years after the vaccination. This was not accompanied by clinically observed measles. Most likely, it was due to an inapparent measles infection in a population considered highly immune after vaccination.

Child mortality related to seroconversion or lack of seroconversion after measles vaccination.

When blood samples were analyzed for seroconversion after measles vaccination, it was discovered that the vaccine had been ineffective for a certain period. During the 2 years between vaccination and the time of seroanalysis, nonseroconverters had a significantly higher mortality than seroconverters (P less than 0.05). The incidence of measles among nonseroconverters was 30% during the period. Between 9 months and 3 years of age, cumulative mortality was 15.1% for nonseroconverters and 4.5% for seroconverters. The difference in mortality was larger when high risk groups (twins, motherless children) were excluded from the analysis (P less than 0.01). The difference in mortality was particularly marked among children vaccinated in the age group 9 to 11 months. This as well as other community studies suggest that measles vaccination reduces child mortality from the age of vaccination by at least 30%.

Herpes simplex infection in relation to kidney allograft survival.

Active infection with one of the herpes viruses, Cytomegalovirus, clearly worsens renal allograft survival. In the present study serologic evidence of infection with another herpes virus, Herpes simplex, was compared with graft survival in 89 cadaveric renal graft recipients transplanted during a two-year period at the Aarhus Center. With respect to Herpes simplex complement-fixing serum antibody status post-transplant, three groups could be identified: 1) No change in antibody titer (25 patients); 2) Significant (4-fold) or more antibody rises (41 patients); 3) No demonstrable antibody (23 patients). Actuarial graft survival was not significantly different in the three groups and thus Herpes simplex infection, in contrast to Cytomegalovirus, does not appear to influence the outcome of renal allograft transplantation.

Prevalence of IgG-antibodies to mumps and measles virus in non-vaccinated children.

The prevalence of mumps and measles IgG antibodies in a randomly selected population of children was determined by an enzyme-linked immunosorbent assay (ELISA) before routine measles-mumps-rubella (MMR) vaccination was introduced in Denmark. Testing of sera from about 2,520 Danish children between one and 17 years of age showed that mumps antibodies were acquired at an early age. The peak acquisition rate was between the ages of four and five; before the age of 15, 90% of children had antibodies to mumps. Immunity to measles occurred at an even earlier age; more than 50% of four-year-old and nearly all (98%) nine-year-old children had IgG antibodies to measles virus. The study showed that about 10% of the young adult Danish population was still susceptible to mumps infection whereas only about 1% of individuals at age 17 had not acquired immunity to measles virus.

Malaria chemoprophylaxis in travellers to east Africa: a comparative prospective study of chloroquine plus proguanil with chloroquine plus sulfadoxine-pyrimethamine.

As malaria caused by Plasmodium falciparum has become resistant to chloroquine alternative drug regimens need to be developed. The prophylactic efficacy against malaria and the side effects of chloroquine phosphate 500 mg weekly with proguanil hydrochloride 200 mg daily was compared with the efficacy of chloroquine 500 mg weekly with sulfadoxine 500 mg-pyrimethamine 25 mg weekly in a randomised study of Scandinavian travellers to Kenya and Tanzania during 1984-5. A total of 767 subjects (416 male and 351 female; 384 taking chloroquine phosphate with proguanil hydrochloride and 383 taking chloroquine with sulfadoxine-pyrimethamine) completed a diary on the breakthrough of malaria and the side effects of treatment while taking the drugs. They were also asked to make thick blood films when symptoms like those of malaria occurred, which were sent to and analysed in Denmark. Four subjects taking chloroquine with proguanil hydrochloride and three taking chloroquine with sulfadoxine-pyrimethamine developed falciparum malaria, which was verified microscopically. Side effects were reported by 36 subjects taking chloroquine phosphate with proguanil hydrochloride and 55 taking the other regimen (p = 0.043). The side effects of both regimens were generally mild, but the combination of chloroquine phosphate with proguanil hydrochloride is recommended because it results in fewer side effects. As breakthroughs of malaria occurred at the earliest after seven weeks self treatment should not be recommended for travellers staying only a short time. Thick blood films are useful for diagnosis of suspected cases of malaria, can be prepared by non-specialists in Africa, and can be analysed successfully after long delays.