A randomised control trial to evaluate the effectiveness of a commercial vaccine for pinkeye in Australian beef cattle.

Pinkeye (a generic term to describe infectious bovine keratoconjunctivitis) is a significant disease of cattle worldwide, impacting productivity and animal welfare. One commercial pinkeye vaccine, a systematically administered Moraxella bovis bacterin, has been available in Australia since 2007. This is the first field trial of the effectiveness of this vaccine for the prevention of naturally occurring disease in Australia. Extensively run beef herds in southwest Queensland that regularly experienced pinkeye were enrolled in the trial and animals were randomly allocated to vaccinated and control groups in different proportions in each herd. The subsequent incidence of clinical pinkeye between the two groups was compared for animals less than one-year-old. Data were analysed from 649 cattle from five herds over two pinkeye seasons: three herds of 390 calves from 1st November 2019 to 20th January 2020 and two herds of 259 calves from 23rd September 2020 to 21st April 2021. Pinkeye was common with 24% of all calves (156/649) contracting the disease during the trial. Univariable and multivariable binary logistic mixed-effect models were fitted to account for clustered data and potential residual confounding due to sex, weight, breed, coat colour, and periocular pigmentation. The incidence of pinkeye was not significantly different between vaccinated and control groups, both alone (p = 0.67) and after adjusting for sex and weight differences (p = 0.69). The vaccine was not protective against naturally occurring pinkeye under the field conditions.

Vaccination inhibits the human adenoviral transduction in a mouse keratoconjunctivitis model.

Adenovirus infections are a major cause of epidemic keratoconjunctivitis (EKC), which can lead to corneal subepithelial infiltrates and multifocal corneal opacity. In the current study, we investigated the use of an E1/E3-deleted adenovirus serotype 5 (Ad5) vector as a vaccine administered intramuscularly (IM) or intranasally (IN) against subsequent challenges with a luciferase-expressing Ad5 (Ad5-Luci) vector via eyedrop. We evaluated the adaptive immune response to Ad5 vector vaccination and confirmed a robust polyfunctional CD8 T cell response in splenic cells. Neutralizing Ad5 antibodies were also measured in the sera of vaccinated mice as well as Ad5 antibody in the eye wash solutions. Upon challenge with Ad5-Luci vector 8 weeks post the primary immunization, transduction was significantly reduced by > 70% in the vaccinated mice, which was slightly better in IM- vs. that in IN-vaccinated animals. Resistance to subsequent challenge was observed 10 months post primary IM vaccination, with sustained reduction up to 60% in the Ad5-Luci vector transduction. Passive immunization of naive mice with antisera from IM to vaccinated mice subsequently challenged with the Ad5-Luci vector resulted in approximately 40% loss in transduction efficiency. Furthermore, the mice that received IM immunization with or without CD8 T cell depletion showed > 40% and 70% reductions, respectively, in Ad8 genomic copies after Ad8 topical challenge. We conclude that Ad-vector vaccination successfully induced an adaptive immune response that prevented subsequent Ad transduction in the cornea and conjunctiva-associated tissues in a mouse model of adenovirus keratoconjunctivitis, and that both cellular and humoral immunity play an important role in preventing Ad transduction.

Efficacy of compartmentalization in controlling an adenovirus type 54 keratoconjunctivitis outbreak on Oki Island, Japan.

PURPOSE: To analyze the epidemiologic characteristics of an outbreak of human adenovirus type 54 (HAdV-54) on Oki Island, Shimane Prefecture, Japan, in 2017 and to assess the effectiveness of a compartmentalization method in controlling the incidence and spread. STUDY DESIGN: Retrospective cohort study. METHODS: The infection was diagnosed in 136 individuals, and typing was confirmed by PCR and direct sequencing. The epidemiologic characteristics of the disease including the infection rate, incubation period, and basic reproductive number (R0), ie, number of cases directly infected by an infectious patient during the course of the disease, were investigated. The effectiveness of compartmentalization for infection control was determined by simulating the outbreak using the Susceptible-Exposed-Infectious-Recovered (SEIR) model. RESULTS: The majority of the HAdV-54-infected individuals were the children of 3 nursery schools (A, B, and C) and their parents on Oki Island. The infection rates in the 3 schools were 13.2%, 16.9%, and 17.2%, respectively. The one class of school B without the index case was initially compartmentalized, and the infection rate in this compartment was 0%. The incubation period was calculated to be 9.3 ± 3.5 days, and the disease duration, 13.0 ± 5.4 days. The R0 was 1.43. Using these parameters, a SEIR model was constructed. The SEIR model well predicted the daily incidence of infection and indicated that the compartmentalization method provides effective reduction in the incidence of the infection, with much earlier control. CONCLUSIONS: The compartmentalization method is effective to control HAdV-54 outbreaks.

[Outbreak of epidemic keratoconjunctivitis caused by human adenovirus serotype 8 in a nursing home.] / Brote de queratoconjuntivitis epidémica por adenovirus humano serotipo 8 en una residencia de mayores.

OBJECTIVE: Ocular infections caused by human adenovirus are highly contagious and can cause outbreaks, especially in nursing homes. In this work, we describe the epidemiological and analytical research as well as the control measures carried out for a conjunctivitis outbreak. METHODS: Descriptive epidemiological study. Cases with a symptom onset date prior to oficial communication were analyzed retrospectively. The rest was analyzed prospectively. Conjunctival smears were collected for microbiological study. Virological analysis was performed by detecting adenovirus by PCR and genotyping. A data questionnaire that collected clinical and epidemiological information was designed. Possible risk factors associated with infection were studied by calculating the Odds Ratio. RESULTS: On June 11, 2019, the Epidemiological Surveillance Section of the Provincial Health Department of Albacete was notified of the existence of a large number of cases of conjunctivitis in a geriatric center. 54 cases were declared: 43 internal residents, 3 day center assistants and 8 workers. Attack rates were 35.8%, 12.5% and 8.4% respectively. Three risk factors were associated with the disease: patient´s lack of autonomy, being a resident at the nursing home and having their room assigned on the first floor. Human adenovirus serotype 8 was detected in the patients' samples. CONCLUSIONS: A high attack rate was observed in internal residents and the disease was associated with patient´s lack of autonomy and having their room assigned on the first floor of the nursing home. The outbreak was caused by human adenovirus serotype 8.

OBJETIVO: Las infecciones oculares causadas por adenovirus humanos son altamente contagiosas y pueden causar brotes, especialmente en residencias de ancianos. El objetivo de este trabajo fue exponer las investigaciones epidemiológicas y analíticas realizadas para el estudio del brote de queratoconjuntivitis epidémica y las medidas establecidas para su control. METODOS: Se realizó un estudio epidemiológico descriptivo. Se analizaron de forma retrospectiva los casos con fecha de inicio de síntomas anterior a la comunicación oficial, y de forma prospectiva el resto. Se recogieron frotis conjuntivales para estudio microbiológico. El análisis virológico fue realizado mediante la detección de adenovirus por PCR y genotipado. Se diseñó un cuestionario de datos que recogía información clínica y epidemiológica. Se estudiaron posibles factores de riesgo asociados a la infección mediante el cálculo de la Odds Ratio. RESULTADOS: El 11 de junio de 2019 se notificó a la Sección de Vigilancia Epidemiológica de la Dirección Provincial de Sanidad de Albacete la existencia de un número elevado de casos de conjuntivitis en un centro geriátrico. Se declararon 54 casos: 43 entre residentes internos, 3 entre asistentes del centro de día y 8 entre personal laboral. Las tasas de ataque fueron del 35,8%, 12,5% y 8,4%, respectivamente. La falta de autonomía, el ser residente interno y estar ubicado en la primera planta fueron factores asociados a la enfermedad. Se detectó adenovirus humano serotipo 8 en las muestras correspondientes a enfermos. CONCLUSIONES: Se observó una elevada tasa de ataque en residentes internos y la enfermedad se asoció con la falta de autonomía y la localización en la primera planta. El brote fue causado por adenovirus humano serotipo 8.

Evaluation of the Anti-Adenoviral Activity of ALTANT, an Ozonated Alcohol Disinfectant.

Seven human mastadenovirus (HAdV) species (A-G) are known with more than 100 reported types. HAdV is highly resistant to common hand sanitizers. Epidemic keratoconjunctivitis and pharyngoconjunctival fever are caused by HAdV, which can be explosively transmitted in a confined space, resulting in outbreaks, such as nosocomial infections. Given the absence of an antiviral agent against the HAdV infection, it is important to prevent the spread of the infection by using disinfectants. Ozone has already been well-known for its bactericidal and virucidal effects. ALTANT is an ozonated alcohol preparation developed by E-TECH Co., Ltd. (Kobe, Hyogo, Japan). In this study, we mixed ALTANT with different HAdV types at a ratio of 9:1 and determined HAdV viability after instantaneous reactions for varying periods (flash to 5 minutes) using the TCID50 assay. The assay results demonstrated that the HAdV viability decreased by 1/10 to 1/100 within 1 minute after the reaction; additionally, slight differences in the reactivity were observed among the HAdV types. HAdV viability decreased by a factor of > 4log10, and the virus was eliminated within 3 minutes. This study demonstrated the potent HAdV disinfection effect of ALTANT.

A 2-year randomized blinded controlled trial of a conditionally licensed Moraxella bovoculi vaccine to aid in prevention of infectious bovine keratoconjunctivitis in Angus beef calves.

BACKGROUND: Infectious bovine keratoconjunctivitis (IBK) in beef cattle has major welfare and production implications. Effective vaccination against IBK would also reduce antibiotic use in beef production. OBJECTIVE/HYPOTHESIS: To evaluate the efficacy of a conditionally licensed commercial IBK vaccine containing Moraxella bovoculi bacterin. Primary working hypothesis was that animals vaccinated with 2 doses of the commercial M. bovoculi vaccine would have a lower risk of disease. ANIMALS: Spring born calves at a university cow-calf herd. After excluding animals with ocular lesions, calves eligible for prevention assessment in 2017 and 2018 were 163 (81 vaccinated, 82 unvaccinated) and 207 (105 vaccinated, 102 unvaccinated). One hundred sixty two and two hundred and six calves completed the follow-up period in 2017 and 2018, respectively. METHODS: A randomized controlled trial. The trial design was a 2-arm parallel trial with a 1:1 allocation ratio. RESULTS: In both years, calves receiving the vaccine had more IBK. This effect was small. The pooled risk ratio was 1.30 (95% confidence interval 0.84-2.01). The pooled unadjusted difference in mean weight (kg) at weaning was -0.88 (95% confidence interval-7.2-5.43). CONCLUSIONS AND CLINICAL IMPORTANCE: We were unable to document that the M. bovoculi bacterin vaccine had a protective effect for the incidence of IBK in our single herd in a 2-year study.

Identification of novel adenovirus genotype 90 in children from Bangladesh.

Novel adenovirus genotypes are associated with outbreaks of disease, such as acute gastroenteritis, renal disease, upper respiratory tract infection and keratoconjunctivitis. Here, we identify novel and variant adenovirus genotypes in children coinfected with enterotoxigenic Escherichia coli, in Bangladesh. Metagenomic sequencing of stool was performed and whole adenovirus genomes were extracted. A novel species D virus, designated genotype 90 (P33H27F67) was identified, and the partial genome of a putative recombinant species B virus was recovered. Furthermore, the enteric types HAdV-A61 and HAdV-A40 were found in stool specimens. Knowledge of the diversity of adenovirus genomes circulating worldwide, especially in low-income countries where the burden of disease is high, will be required to ensure that future vaccination strategies cover the diversity of adenovirus strains associated with disease.

Enhancing best practices in ophthalmology for prevention of nosocomial epidemic keratoconjunctivitis infections.

Epidemic keratoconjunctivitis (EKC) outbreaks were reported as early as the 1940s in the United States. Nearly 80 years later, EKC remains a major eye health concern in the US and worldwide. Of particular concern is that a significant number of EKC cluster outbreaks in the US are healthcare acquired infections (HAIs) at ophthalmology offices. Therefore, immediate attention to enhancing best practices of standardization and universal precautions in ophthalmology is paramount.

[Adenoviral keratoconjunctivitis]. / Adenovirus-Keratokonjunktivitis.

Keratoconjunctivitis caused by adenoviruses (epidemic keratoconjunctivitis, EKC, ICD-10 B30.0+) is common, can be severe and may cause significant morbidity. In the early stages of adenoviral infections it is often difficult to differentiate the clinical presentation from other causes of a red eye. Because of its highly contagious nature that can rapidly lead to epidemic outbreaks, prompt viral identification and prevention of further spread are major challenges. Even today the diagnosis is still mainly clinical, with laboratory tests only rarely contributing. New diagnostic tests, such as the Rapid Pathogen Detector (RPS, Sarasota FL) AdenoPlus detection kit, that are practical, rapid and inexpensive to use in the general practice may obviate these problems. Because of its highly resistant properties to desiccation and highly developed escape mechanisms which protect the virus from the host's immune response, long-term problems often remain. Remnants of viral proteins often persist on the corneal surface of Bowman's layer for a long time and may lead to the formation of subepithelial infiltrates. No treatment other than symptomatic eye drops is available. The major sequelae are subepithelial infiltrates, which are difficult to treat. Cyclosporin A eye drops are a good option with a low risk profile. The use of topical steroids can possibly be disadvantageous but can be discussed at all stages of the disease. As nosocomial spread of adenoviruses is relatively common, preventive measures remain a major responsibility for ophthalmologists.

A systematic review and cost-effectiveness analysis of tonometer disinfection methods.

OBJECTIVE: The Goldmann applanation tonometer presents the problem of being one of the most widely used pieces of equipment in the ophthalmic clinic and a known risk factor for the transmission of epidemic keratoconjunctivitis (EKC). The purpose of this review is to assess the effectiveness of 3 methods of disinfection: alcohol swabs, immersion in peroxide, and the use of disposable prisms. An economic evaluation is undertaken to assess the cost-effectiveness of the 3 alternatives. In doing so, we contribute an evidence-based overview of the issue at an opportune time, because several jurisdictions are developing protocols regarding tonometer tip disinfection. DESIGN: Systematic review and cost-effectiveness analysis. METHODS: A comprehensive literature review was undertaken with a librarian, comprising searches of 6 electronic databases and hand searches of the grey literature. A 3-level screening process was undertaken by 2 reviewers according to prespecified inclusion and exclusion criteria. Values from included papers were used to inform a cost-effectiveness analysis undertaken using a decision tree model implemented in TreeAge. The analysis was undertaken from the hospital perspective and included all equipment and labour costs. RESULTS: Synthesis of in vitro data indicates that all 3 methods are plausible methods of disinfection with a 64% reduction in log growth of EKC when peroxide is used compared with alcohol swabs. The incremental cost-effective ratios from the cost-effectiveness analysis were $12,000/case averted using peroxide and $61,000/case averted with Tonosafe as compared with alcohol. CONCLUSIONS: Assuming clinical infection rates match in vitro disinfection data, the cost of bleach is high and the cost of Tonosafe is unacceptably high to reduce 1 potential case of adenoviral keratoconjunctivitis.

Immunogenicity of a new recombinant IpaC from Shigella dysenteriae type I in guinea pig as a vaccine candidate.

BACKGROUND: Recombinant vaccine technology is one of the most developed means in controlling infectious diseases. However, an effective vaccine against Shigella is still missing. OBJECTIVE: To evaluate recombinant IpaC protein of Shigella as a vaccine candidate. METHODS: In this study we cloned IpaC gene into an expression vector in prokaryotic system. The protein expression was evaluated by SDS-PAGE and Western-Blotting analysis. The recombinant protein was purified using Ni-NTA affinity chromatography. Guinea pigs were immunized with the recombinant protein and the level of immunogenicity was examined by ELISA and Western blotting of IpaC. Challenge test was done through the intraoculary injection of Shigella dysenteriae (6×108 CFU/eye) and after 48 hours was scored for keratoconjunctivitis. RESULTS: The results showed a remarkable level of immunogenicity in terms of antibody response and protection against keratoconjunctivitis in tested animals. The recombinant IpaC protein provided a protective system against Shigella dysenteriae type I during the challenge test. CONCLUSION: The results showed the potential of using recombinant IpaC in preparation of vaccine in perspective studies.

Epidemic adenoviral keratoconjunctivitis possibly related to ophthalmological procedures in a neonatal intensive care unit: lessons from an outbreak.

PURPOSE: Epidemic adenoviral keratoconjunctivitis can spread rapidly among preterm infants who frequently undergo ophthalmological examination. Here we present our experience on a nosocomial outbreak that affected 8 nursery staff members and 26 premature infants. We focus on the presentation and progress of the outbreak, the diagnosis of the disease and the measures taken for its control. METHODS: Data were collected from patients' files and records of the infection control team. Conjunctival swabs were collected to perform direct fluorescent assay (DFA) and viral culture. Diagnosis was made according to clinical evidence and/or detection of the virus. Statistical analysis was performed using SPSS 15.0 statistical software. RESULTS: Infection was introduced to our unit after a laser photocoagulation procedure of a 28-week gestational infant and circulated rapidly within the unit due to direct transmission through contaminated medical equipment, fomites and hands of nursery staff members. Neither the patients, nor the nursery staff members developed systemic symptoms. While DFA tests were positive in seven infants, culture positivity could be demonstrated in only three infants. Contact and droplet precautions were implemented with the recommendation of the infection control team. No recurrence occurred after definition of the last case on the 32nd day. CONCLUSION: Ophthalmologic procedures continue to be a potential source of adenovirus outbreaks. However, negligence of contact measures during routine daily nursing care seems to be a more important contributing factor for rapid spread. Strict adherence to appropriate aseptic procedures is required to prevent this potentially hazardous infection in preterm infants.

A solution to the Jones tube continuous positive airway pressure (CPAP) dilemma?

A 49-year-old woman, who had previously undergone bilateral Jones tube placement, began nasal continuous positive airway pressure for obstructive sleep apnea. The patient's use of continuous positive airway pressure was limited by intolerance of the transfer of air through the Jones tube to her ocular surface resulting in irritation and discomfort. A change from nasal continuous positive airway pressure to a full face mask, including both Jones tubes in the pressure circuit, resolved the problem.

Epidemic keratoconjunctivitis: the current situation and recommendations for prevention and treatment.

BACKGROUND: Epidemic keratoconjunctivitis (EKC) is a highly contagious infection of the ocular surface. 316 cases were diagnosed in Germany in the first 8 months of 2010, corresponding to a 300% increase above the typical figures for recent years. This outbreak motivates us to present the current recommendations concerning EKC. METHODS: Selective literature review. RESULTS: EKC is an adenoviral infection that typically starts with a unilateral foreign body sensation and then develops, within a few hours or days, into bilateral keratoconjunctivitis with marked chemosis, epiphora, and photophobia. Visual impairment can persist for months because of subepithelial corneal infiltrates (nummuli) and irregular astigmatism. Randomized clinical trials have not shown any clear benefit in the acute phase from any of a variety of treatments, including steroids, calcineurin inhibitors, virostatic drugs and disinfecting agents. In the chronic phase, cyclosporin A eye drops can accelerate the regression of subepithelial infiltrates. Hygienic measures, including conscientious hand and surface disinfection, can lessen the spread of the disease. CONCLUSION: The first priority in the treatment of patients with definite or suspected EKC is the rigorous application of hygienic measures in medical facilities, particularly because there is still no effective drug treatment for this disease. No virostatic agent has yet been demonstrated to influence its course, either subjectively or objectively.

Prevention of cytarabine-induced kerato-conjunctivitis by eye rinse in patients receiving high-dose cytarabine and total body irradiation as a conditioning for hematopoietic stem cell transplantation.

We previously reported a high incidence of kerato-conjunctivitis in patients receiving high-dose cytarabine following total body irradiation (TBI) as a conditioning for hematopoietic stem cell transplantation (HSCT) even on prophylaxis with topical corticosteroid. This study aimed to evaluate whether addition of eye rinse, which was designed to remove cytarabine from ocular surface, further reduces the incidence of kerato-conjunctivitis in the same setting. Seventy-six patients receiving cytarabine at a dose of 3 g/m(2) every 12 h for 4 days after receiving TBI (12 Gy) as conditioning for HSCT were evaluated. All patients received betamethasone sodium phosphate eye drops. Twenty-three patients were further instructed to rinse their eyes with sterile saline every 10-15 min during and for two additional hours after the completion of each cytarabine infusion. Among 23 patients with eye rinse, Grades 2-3 and 1-3 kerato-conjunctivitis were observed in 4 (17.4%) and 5 patients (21.7%), respectively. These incidences were significantly lower than those [35 (66.0%) and 41 (77.4%)] observed in 53 patients without eye rinse (P < 0.001 and P < 0.00001, respectively). These results strongly suggest that eye rinse effectively reduces the incidence and severity of cytarabine-induced kerato-conjunctivitis in HSCT recipients who receive high-dose cytarabine following TBI.

Prophylactic treatment for cytosine arabinoside-induced keratoconjunctivitis.

High-dose cytosine arabinoside (Ara-C) is known to cause keratoconjunctivitis in a large proportion of patients. Topical steroids are a popular choice of prophylactic treatment. The objective of this survey was to evaluate the type, dose, frequency and duration of drops used in all centres (n = 117) participating in the acute myeloid leukaemia trial 15 (AML 15), and to assess adherence to the trial protocol prescribed guidelines. All centres used prophylactic treatment; however, the dose of Ara-C at which it was initiated varied from 100 to 6000 mg/m(2)/day. All centres used some form of steroid prophylaxis with prednisolone 0.5% being the most commonly used (98/117), but only 6 of the 117 centres initiated treatment at doses recommended in the trial protocol. Ten centres used lubricants in addition to steroids. No centre reported the use of non-steroidal anti-inflammatory drops. The duration of treatment ranged from 2 days prior to commencing Ara-C to 28 days post-treatment. Twenty-two centres reported complications of which preservative allergy was the commonest. There is a large variation in prophylactic treatment practice in the UK. Clear guidance on the use of prophylaxis and further studies are required to ascertain the most effective prophylactic treatment and regimen.

Brote de queratoconjuntivitis epidémica en un Servicio de Oftalmología / A nosocomial outbreak of epidemic keratoconjunctivitis

We describe a nosocomial outbreak of keratoconjunctivitis at the Ophthalmology Clinic in Hospital Carlos Van Buren, that affected 150 patients, during August and September of 2006. This outbreak was concomitant with a community outbreak produced by the same agent in the city of Valparaiso that affected 681 other patients. Although adenovirus was not isolated in the nosocomial cases, positive cultures were obtained from community cases, so the diagnosis was based on clinical and epidemiological criteria. The infection rate within the Clinic patients was 5.2 percent considering the population that attended the Clinic in this period. The evaluation of patient care practices showed that common risk factors among affected cases were measurement of ocular tension with a tonometer in the Ophthalmology Clinic (without disinfection of the tonometer between patients), contamination of work surfaces (equipment, furniture), and poor compliance of hand hygiene. Control measures adopted were cleaning, disinfection of tonometer, equipment and work surfaces, and reinforcement of hand hygiene measures. With these measures, it was possible to control the nosocomial outbreak, despite the continued outpatient care of community-acquired cases.

Se describe un brote nosocomial de queratoconjun-tivitis epidémica en la Policlínica de Oftalmología del Hospital Carlos Van Burén, que afectó a 150 pacientes, durante los meses de agosto y septiembre de 2006. Este brote se presentó en el contexto de un brote en la ciudad de Valparaíso que afectó a otros 681 pacientes. Aun cuando no se logró aislar adenovirus (ADV) en los casos nosocomiales, se aisló ADV en pacientes del brote comunitario, por lo que el diagnóstico de los casos nosocomiales se basó en criterios clínicos y epidemiológicos. La tasa de ataque del brote nosocomial fue de 5,2 por ciento considerando la población consultante del período. La evaluación de prácticas de atención directa mostró que los factores de riesgo de los casos serían la medición de la tensión ocular mediante tonómetro en la Policlínica de Oftalmología (sin desinfección del tonómetro entre paciente y paciente), contaminación de superficies de trabajo (equipos, mobiliario) y bajo cumplimiento de la higienización de manos. Las medidas de control fueron limpieza, desinfección del tonómetro, equipos y superficies de trabajo, junto a reforzamiento de lavado de manos. Con estas medidas se logró controlar el brote intrahospitalario a pesar de mantenerse las consultas provenientes del brote en la comunidad.

Photoprotection: a review of the current and future technologies.

Exposure to ultraviolet (UV) radiation is associated with a variety of harmful effects ranging from photoaging to skin cancer. UVB (290 to 320 nm) directly damages the cellular DNA leading to the formation of the 6-4 cyclobutane pyrimidine dimmers, and UVA (320 to 400 nm) indirectly damages the DNA via the production of oxygen radical species. In this review, we focused on the technological and scientific aspects of photoprotection using sunglasses and clothing while attempting to dispel some of the misconceptions. In addition to the basic knowledge relating to sunscreens, we reviewed the current guidelines for testing and labeling UVA protection around the world, controversies associated with nanoparticles, and future sunscreens actives waiting for the Food and Drug Administration approval. Lastly, we reviewed alternative agents, such as antioxidants, that can be used to supplement and augment photoprotection provided by sunscreens.