An influenza A (H3N2) virus outbreak in the Kingdom of Cambodia during the COVID-19 pandemic of 2020.

BACKGROUND: Global influenza virus circulation decreased during the COVID-19 pandemic, possibly due to widespread community mitigation measures. Cambodia eased some COVID-19 mitigation measures in June and July 2020. On 20 August a cluster of respiratory illnesses occurred among residents of a pagoda, including people who tested positive for influenza A but none who were positive for SARS-CoV-2. METHODS: A response team was deployed on 25 August 2020. People with influenza-like illness (ILI) were asked questions regarding demographics, illness, personal prevention measures, and residential arrangements. Respiratory swabs were tested for influenza and SARS-Cov-2 by real-time reverse transcription PCR, and viruses were sequenced. Sentinel surveillance data were analyzed to assess recent trends in influenza circulation in the community. RESULTS: Influenza A (H3N2) viruses were identified during sentinel surveillance in Cambodia in July 2020 prior to the reported pagoda outbreak. Among the 362 pagoda residents, 73 (20.2%) ILI cases were identified and 40 were tested, where 33/40 (82.5%) confirmed positive for influenza A (H3N2). All 40 were negative for SARS-CoV-2. Among the 73 residents with ILI, none were vaccinated against influenza, 47 (64%) clustered in 3/8 sleeping quarters, 20 (27%) reported often wearing a mask, 27 (36%) reported often washing hands, and 11 (15%) reported practicing social distancing. All viruses clustered within clade 3c2.A1 close to strains circulating in Australia in 2020. CONCLUSIONS: Circulation of influenza viruses began in the community following the relaxation of national COVID-19 mitigation measures, and prior to the outbreak in a pagoda with limited social distancing. Continued surveillance and influenza vaccination are required to limit the impact of influenza globally.

Predictors of smear-negative pulmonary tuberculosis in HIV-infected patients, Battambang, Cambodia.

DESIGN: Retrospective data analysis of human immunodeficiency virus (HIV) infected patients attending an HIV clinic (referral hospital), Cambodia. Chest X-rays (CXRs) were read independently by onsite and offsite physicians. RESULTS: Data on 881 patients were analyzed (smear-negative = 776, smear-positive = 105). Overall, the prevalence of culture-confirmed pulmonary tuberculosis (PTB) was 17% (150/881, smear-negative = 62/150). For those with any positive culture, a smear-negative case was four times more likely to be mycobacteria other than tuberculosis (MOTT) than Mycobacterium tuberculosis (P = 0.001). Median CD4 count was higher in smear-negative than smear-positive PTB patients (92.5 vs. 42, P = 0.24). Age, symptoms (cough >3 weeks or hemoptysis or fever >1 month) (aOR 2.6, P = 0.02) and an abnormal CXR (offsite reading) (aOR 4.9, P < 0.001) were significant predictors of smear-negative PTB. CXR was no longer significant in the model using the onsite reading (aOR 1.6, P = 0.11). The combination of age >or=30 years plus symptoms had a sensitivity of 100% but a positive predictive value (PPV) of 9%. CXR (offsite), as the next diagnostic test, had a sensitivity of 50% and specificity of 83%. The sensitivity of smear microscopy was 59% and its specificity 97%. CONCLUSIONS: While age and symptoms are useful both in screening smear-negative PTB suspects and in predicting smear-negative PTB cases, they have limited PPV. Given the limitations of smear microscopy, culture is required to diagnose smear-negative disease. Where culture is unavailable, CXR is an important adjunct for diagnosis. However, inaccurate CXR interpretation can impact case detection.

Pulmonary tuberculosis among patients visiting a voluntary confidential counseling and testing center, Cambodia.

SETTING: Voluntary counseling and confidential testing center (VCCT), Battambang District, Cambodia. OBJECTIVES: To determine newly diagnosed pulmonary tuberculosis (PTB) prevalence and predicting factors, and assess the utility of TB-related symptoms and yield of sputum microscopy and culture. DESIGN: Cross-sectional survey using interview, sputum smears and cultures and human immunodeficiency virus (HIV) testing. RESULTS: Of 496 participants, 29 (5.8%) had culture-confirmed PTB while 19 (65.5%) were acid-fast bacilli (AFB) smear-positive. PTB prevalence was higher (P < 0.001) in HIV-positives (20/124, 16.1%) than in HIV-negatives (9/372, 2.4%). On multivariable analysis, being HIV-positive, underweight (body mass index <18.5 kg/m(2)), rapid weight loss and age > or =35 years were predictors of PTB. Fever (93%) and hemoptysis (86%) had the highest sensitivity and specificity, respectively. The symptom complex of rapid weight loss, fever and hemoptysis detected all PTB cases (sensitivity 100%). Examination of three sputum smears with culture of the first sample detected 95% (19/20) of the HIV-associated PTB cases and 90% (26/29) overall. CONCLUSIONS: TB is common in the VCCT setting, regardless of HIV status. The high prevalence of HIV and PTB among the participants warrants consideration of TB screening for all HIV suspects. Such screening through VCCT is feasible. Adding a single culture test to the evaluation of an initial sputum sample set will substantially increase case detection.

In vitro activity of amphotericin B, fluconazole and voriconazole against 162 Cryptococcus neoformans isolates from Africa and Cambodia.

In order to determine the potential role that various antifungal agents might have in the management of cryptococcosis in tropical areas, the in vitro susceptibility of Cryptococcus neoformans isolates from Africa ( n=52) and Cambodia ( n=110) to three antifungal agents (amphotericin B, fluconazole and voriconazole) were compared using the E-test method. The results of this study (i) confirm the value of the E-test for testing the in vitro susceptibility of C. neoformans towards voriconazole; (ii) provide the first evidence demonstrating good activity of amphotericin B, fluconazole and voriconazole against Cambodian isolates; and (iii) show there are differences in susceptibility between African and Asian C. neoformans isolates, with Cambodian isolates appearing less susceptible to the agents tested but with amphotericin B maintaining good activity.

Hypertensive diabetic patients: guidelines for conduct and their difficulties.

OBJECTIVE: To assess the effect of blood pressure (BP) control and other cardiovascular risk factors in patients with diabetes mellitus in a referral service for the treatment of hypertension. METHODS: A retrospective study where diabetic patients (at least 2 fasting glucose levels above 126 mg/dL, use of hypoglycemic agents or insulin, or both of these) were included. They were evaluated at the first appointment (M1) and at the last appointment (M2), regarding blood pressure, body mass index (BMI), use of hypertensive drugs, glycemia, total cholesterol (TC), creatinine, and potassium. RESULTS: Of 1,032 patients studied, 146 patients with a mean age of 61.6 years had diabetes, and 27 were men (18.5%). Mean follow-up was 5.5 years. BP values were 161.6 x 99.9 mmHg in M1 and 146.3 x 89.5 mmHg in M2. In M1, 10.4% of the patients did not use medications, 50.6% used just 1 drug, 30.8% used 2 drugs, and 8.2% used 3 or more drugs. In M2, these values were 10.9%, 39%, 39.7%, and 10.4%, respectively. Diuretics were the most commonly used medication, whereas angiotensin-converting enzyme inhibitors (ACE inhibitors) were those drugs which presented greater increase when comparing M1 to M2 (24.6% and 41.7%, respectively). Only 17,1% reached the recommended goal (BP<130x85 mmhg). The other cardiovascular risk factors did not change significantly. CONCLUSION: Our data reinforce the necessity of a more aggressive approach in the treatment of these patients, despite the social and economic difficulties in adhering to treatment.

Induction of monocyte chemoattractant protein-1 (MCP-1) production by Pseudomonas nitrite reductase in human pulmonary type II epithelial-like cells.

Monocyte chemoattractant protein-1 (MCP-1), a chemoattractant for monocytes, is presumed to play a pivotal role in the recruitment and accumulation of monocytes in various diseases including pulmonary infections. We examined here whether or not Pseudomonas nitrite reductase (PNR), a recently identified IL-8 inducer in various respiratory cells, could stimulate human pulmonary type II epithelial-like cells (A549) to induce MCP-1 production. A time- and dose-dependent induction of MCP-1 protein synthesis associated with an increase of MCP-1 mRNA expression by A549 cells was observed in response to PNR. New protein translation was not required for PNR-mediated MCP-1 mRNA expression in the same cells. When anti-human MCP-1 monoclonal antibody was used for neutralizing of monocyte chemotactic factor (MCF) activities in the culture supernatants of these cells stimulated with PNR, significant reductions of MCF activities (the mean reduction rate; 49-59%, P<0. 05) were observed. These data suggest that PNR may contribute to monocyte migration, through inducing pulmonary epithelial cell-derived MCP-1 production in the airway of patients with pneumonia due to P. aeruginosa.

Induction of interleukin 8 (IL-8) production by Pseudomonas nitrite reductase in human alveolar macrophages and epithelial cells.

Interleukin-8 (IL-8) participates in the generation of dense neutrophil accumulations in bronchopulmonary infections caused by Pseudomonas aeruginosa (P. aeruginosa). We have recently reported that nitrite reductase, a bifunctional enzyme located in the periplasmic space of P. aeruginosa, induces IL-8 generation in bronchial epithelial cells (K. Oishi et al. Infect. Immun. 65: 2648-2655, 1997). We examined whether or not Pseudomonas nitrite reductase (PNR) could also stimulate human alveolar macrophages (AM) and pulmonary type II epithelial-like cells (A549) to induce IL-8 production and mRNA expression as well as the production of TNF alpha and IL-1beta. We demonstrated a time- and dose-dependent IL-8 protein synthesis and IL-8 mRNA expression, but no TNF alpha or IL-1beta production, by A549 cells in response to PNR. New protein translation was not required for PNR-mediated IL-8 mRNA expression in the same cells. Furthermore, simultaneous stimulation of PNR with serial doses of TNF alpha or IL-1beta resulted in additive IL-8 production in A549 cells. In adherent AM, PNR enhanced IL-8 protein synthesis and IL-8 mRNA expression in a time-dependent fashion. PNR similarly induced a time-dependent production of TNF alpha and IL-1beta by human adherent AM. Neutralization of TNF alpha or IL-1beta did not influence the levels of IL-8 production in adherent AM culture. We also evaluated whether the culture supernatants of the A549 cells or AM stimulated with PNR could similarly mediate neutrophil migration in vitro. When anti-human IL-8 immunoglobulin G was used for neutralizing neutrophil chemotactic factor (NCF) activities in the culture supernatants of these cells stimulated with 5 microg/ml of PNR, the mean percent reduction of NCF activities were 49-59% in A549 cells and 24-34% in AM. Our present data support that PNR directly stimulates AM and pulmonary epithelial cells to produce IL-8. PNR also mediates neutrophil migration, in part, through IL-8 production from AM and pulmonary epithelial cells. These data suggest the contribution of PNR to the pathogenesis of bronchopulmonary infections due to P. aeruginosa.

Essential role of transcription factor nuclear factor-kappaB in regulation of interleukin-8 gene expression by nitrite reductase from Pseudomonas aeruginosa in respiratory epithelial cells.

Persistent infection with Pseudomonas aeruginosa increases interleukin-8 (IL-8) levels and causes dense neutrophil infiltrations in the airways of patients with chronic airway diseases. Recently, we have reported that nitrite reductase from P. aeruginosa induces the production of IL-8 in respiratory cells, including bronchial epithelial cells. To determine the molecular mechanism(s) of nitrite reductase-induced IL-8 expression in respiratory cells, A549 epithelial cells were transfected with plasmids containing serial deletions of the 5'-flanking region of the IL-8 gene and then exposed to nitrite reductase. Nitrite reductase significantly enhanced IL-8 gene promoter-driven reporter activity. This increased IL-8 gene expression was inhibited by mutating the nuclear factor-kappaB (NF-kappaB) binding element. Nitrite reductase enhanced nuclear localization of the NF-kappaB binding complex. Furthermore, nitrite reductase induced the degradation of IkappaBalpha, the major cytoplasmic inhibitor of NF-kappaB, and the expression of IkappaBalpha mRNA. These data support the critical role of the activation of NF-kappaB in nitrite reductase-induced IL-8 gene expression in airway epithelium.

Nitrite reductase from Pseudomonas aeruginosa released by antimicrobial agents and complement induces interleukin-8 production in bronchial epithelial cells.

We have recently reported that nitrite reductase, a bifunctional enzyme located in the periplasmic space of Pseudomonas aeruginosa, could induce interleukin-8 (IL-8) generation in a variety of respiratory cells, including bronchial epithelial cells (K. Oishi et al. Infect. Immun. 65:2648-2655, 1997). In this report, we examined the mode of nitrite reductase (PNR) release from a serum-sensitive strain of live P. aeruginosa cells during in vitro treatment with four different antimicrobial agents or human complement. Bacterial killing of P. aeruginosa by antimicrobial agents induced PNR release and mediated IL-8 production in human bronchial epithelial (BET-1A) cells. Among these agents, imipenem demonstrated rapid killing of P. aeruginosa as well as rapid release of PNR and resulted in the highest IL-8 production. Complement-mediated killing of P. aeruginosa was also associated with PNR release and enhanced IL-8 production. The immunoprecipitates of the aliquots of bacterial culture containing imipenem or complement with anti-PNR immunoglobulin G (IgG) induced twofold-higher IL-8 production than did the immunoprecipitates of the aliquots of bacterial culture with a control IgG. These pieces of evidence confirmed that PNR released in the aliquots of bacterial culture was responsible for IL-8 production in the BET-1A cells. Furthermore, the culture supernatants of the BET-1A cells stimulated with aliquots of bacterial culture containing antimicrobial agents or complement similarly mediated neutrophil migration in vitro. These data support the possibility that a potent inducer of IL-8, PNR, could be released from P. aeruginosa after exposure to antimicrobial agents or complement and contributes to neutrophil migration in the airways during bronchopulmonary infections with P. aeruginosa.

Nitrite reductase from Pseudomonas aeruginosa induces inflammatory cytokines in cultured respiratory cells.

Persistent infection with Pseudomonas aeruginosa increases interleukin-8 (IL-8) levels and causes dense neutrophil infiltrations in the airway of patients with chronic airway diseases. To investigate the role of P. aeruginosa infection in IL-8 production in the airway of these patients, we examined whether cell lysates of P. aeruginosa could cause IL-8 production from human bronchial epithelial cells. Diluted sonicated supernatants of P. aeruginosa (SSPA) with a mucoid or nonmucoid phenotype stimulated human bronchial epithelial (BET-1A) cells to produce IL-8. In this study, we have purified a 59-kDa heat-stable protein with IL-8-inducing activity from the SSPA by sequential ion-exchange chromatography. The N-terminal sequence of this purified protein completely matched a sequence at the N-terminal part of the mature protein of nitrite reductase from P. aeruginosa. In addition, immunoblotting with a polyclonal immunoglobulin G (IgG) against recombinant Pseudomonas nitrite reductase demonstrated a specific binding to the purified protein. Furthermore, the immunoprecipitates of the SSPA with a polyclonal IgG against recombinant nitrite reductase induced a twofold-higher IL-8 production in the BET-1A cell culture than did the immunoprecipitates of the SSPA with a control IgG. These lines of evidence confirmed that Pseudomonas nitrite reductase was responsible for IL-8 production in the BET-1A cells. The purified nitrite reductase induced maximal expression of IL-8 mRNA in the BET-1A cells at 1 to 3 h after stimulation, and the IL-8 mRNA expression declined by 8 h after stimulation. New protein translation was not required for nitrite reductase-mediated IL-8 mRNA expression in the BET-1A cells. Nitrite reductase stimulated the BET-1A cells, as well as human alveolar macrophages, pulmonary fibroblasts, and neutrophils, to produce IL-8. In contrast, nitrite reductase induced significant levels of tumor necrosis factor alpha and IL-1beta protein only in human alveolar macrophages. These data support the notion that nitrite reductase from P. aeruginosa induces the production of inflammatory cytokines by respiratory cells and may contribute to the pathogenesis of chronic airway diseases and persistent P. aeruginosa infection.