The third pandemic: The respiratory syncytial virus landscape and specific considerations for the allergist/immunologist.

Background: Since its initial identification in 1956, respiratory syncytial virus (RSV) has been the second most common cause of mortality in infants <6 months of age and a major cause of morbidity and mortality associated with lower respiratory tract infection (LRTI) in older adults (ages >60 years) worldwide. Of particular interest to the allergist/immunologist is a growing body of evidence that suggests an association between LRTI caused by RSV in infants with later-life development of asthma, wheezing, or impaired lung function in adults. Efforts to develop a RSV vaccine have been thwarted for >70 years by the occurrence of enhanced respiratory disease (ERD), an adverse RSV vaccine reaction, in the 1960s, in which more-severe illness occurred on natural infection after vaccination of infants who were RSV naive and with a formalin-inactivated RSV vaccine. Recent advances in knowledge of the structural biology of the RSV surface fusion glycoprotein, however, have revolutionized RSV vaccine development for preventive interventions and have offered, at last, the hope of an effective and safe vaccine for the prevention of RSV disease. Objective: The purpose of this report was to examine the current evidence that supports the epidemiology, disease manifestations, molecular biology, treatments, and new vaccine development of RSV vaccines. Results: The host-immune response to RSV infection is carried out by two distinct but overlapping universes of mucosal and systemic immune systems in which a balanced set of B- and T-cell responses are involved in protective immunity that includes the mucosal immune system in which immunoglobulin A (IgA) prevails and the systemic immune system in which IgG neutralizing antibody predominates. The key to developing an effective vaccine is now thought to be linked to the availability of a stabilized prefusion F protein in the immunizing vaccine, which can perform a dual function of a balanced mucosal and/or systemic immune response as well as an effective antibody specifically directed to critical epitopes on the requisite prefusion F protein. Conclusion: The unfortunate manifestation of RSV ERD that occurred in the 1960s has led to a better understanding of the structural biology of the RSV surface fusion glycoprotein and has provided a basis for the development of more effective and safer RSV vaccines and monoclonal antibody preparations for immunoprophylaxis of the dread effects of RSV disease. There are now a large number of clinical trials in progress that are evaluating these products, which include recombinant vector, subunit, particle-based, live-attenuated, chimeric, and nucleic acid vaccines; and monoclonal antibodies. This article gives an overview of the many aspects of RSV disease and development of virus (RSV) vaccines of particular interest to the allergist/immunologist.

Monkeypox viral infection and disease: A challenge for the allergist-immunologist.

Background: Human monkeypox is a zoonosis caused by the monkeypox virus, an orthopoxvirus and close relative of variola virus, the causative agent of smallpox. The disease was first reported in central Africa in 1970, where it continues to be endemic and has historically affected some of the poorest and most marginalized communities in the world. The condition has recently attracted global attention due to >14,000 cases, including five deaths, reported by the World Health Organization, and a total of 5189 confirmed monkeypox cases in the United States reported by the Centers for Disease Control and Prevention as of July 29, 2022. On July 23, 2022, the World Health Organization declared the current monkeypox outbreak a Public Health Emergency of International Concern. Objective: The purpose of the present report was to review the epidemiology of monkeypox viral infection; its clinical manifestations; and current recommendations for diagnosis, treatment, and use of vaccines for prevention of the disease, with a focus on those aspects that have particular relevance to the allergist/immunologist. Results: Monkeypox was discovered in the early 1970s and, for years, has been well described by researchers in west and central Africa, where the disease has been present for decades. Although this outbreak thus far has mostly affected men who have sex with men, it is possible that the disease could become endemic and could begin spreading in settings where there is close physical contact, which is how the virus is transmitted. Conclusion: Monkeypox is a different viral infection from the coronavirus. Unlike the coronavirus, which is an extremely contagious respiratory pathogen, monkeypox is primarily transmitted through body fluids and/or prolonged skin-to-skin contact. Although the control of monkeypox will require renewed efforts and resources, we have learned much from the past and have the tools to stop this virus from becoming yet another serious illness with which Americans have to contend. The allergist/immunologist can play a significant role.

The global burden of vaccine-preventable infectious diseases in children less than 5 years of age: Implications for COVID-19 vaccination. How can we do better?

Background: Infectious diseases are a leading cause of morbidity and mortality worldwide. As of 2018, the total world population of children < 5 years of age was roughly estimated at 679 million. Of these children, an estimated 5.3 million died of all causes in 2018, with an estimated 700,000 who died of vaccine-preventable infectious diseases; 99% of the children who died had lived in low- and middle-income countries. The infectious diseases that remain major causes of mortality for which vaccines have been shown to provide proven preventive success include, in order of prevalence, are those caused by Streptococcus pneumoniae, Rotavirus, Bordetella pertussis, measles virus, Haemophilus influenzae type b and influenza virus. Objective: The purpose of the present report was to address the global burden of these six vaccine-preventable infectious diseases in children < 5 years of age, together with implications for the prevention of coronavirus disease 2019 (COVID-19) infection in children. Methods: The current immunization strategies for the prevention of the six vaccine-preventable infectious diseases in children are reviewed as a framework for new strategies of vaccine prevention of COVID-19 in children. Results: The burden of addressing vaccine prevention of future infectious disease in children can be effectively pursued through knowledge gained from past experiences with vaccine usage in these six vaccine-preventable childhood infectious diseases. Conclusion: Issues with regard to the burden of disease mortality, disease transmission, and available vaccines as well as vaccine successes and shortcomings for specific pathogens can serve as important landmarks for effective use of future vaccines. Although much success has been made globally in preventing these childhood deaths, much remains to be done.

COVID-19 in children: Pathogenesis and current status.

Background: Since its initial description in December 2019 in Wuhan, China, coronavirus disease 2019 (COVID-19) has rapidly progressed into a worldwide pandemic, which has affected millions of lives. Unlike the disease in adults, the vast majority of children with COVID-19 have mild symptoms and are largely spared from severe respiratory disease. However, there are children who have significant respiratory disease, and some may develop a hyperinflammatory response similar to that seen in adults with COVID-19 and in children with Kawasaki disease (KD), which has been termed multisystem inflammatory syndrome in children (MIS-C). Objective: The purpose of this report was to examine the current evidence that supports the etiopathogenesis of COVID-19 in children and the relationship of COVID-19 with KD and MIS-C as a basis for a better understanding of the clinical course, diagnosis, and management of these clinically perplexing conditions. Results: The pathogenesis of COVID-19 is carried out in two distinct but overlapping phases of COVID-19: the first triggered by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) itself and the second by the host immune response. Children with KD have fewer of the previously described COVID-19-associated KD features with less prominent acute respiratory distress syndrome and shock than children with MIS-C. Conclusion: COVID-19 in adults usually includes severe respiratory symptoms and pathology, with a high mortality. It has become apparent that children are infected as easily as adults but are more often asymptomatic and have milder disease because of their immature immune systems. Although children are largely spared from severe respiratory disease, they can present with a SARS-CoV-2-associated MIS-C similar to KD.

Electronic health records-Applications for the allergist/immunologist: All that glitters is not gold.

A review of existing literature on electronic health records (EHR) demonstrates the lack of a comprehensive analysis of the current status of, and impediments for, physicians, including allergists/immunologists, to adopting a fully functioning system. For physicians to logically embrace the use of EHRs, a comprehensive but straightforward presentation of this complex subject would be helpful. In fact, although there is some evaluative information regarding data derived from EHRs about asthma epidemiology and practice guidelines as well as recording adverse allergic reactions, it is impossible to find one scholarly article that evaluated the use of fully functional EHRs from the perspective of an allergist or immunologist. This analysis presents a review of the background and goals of EHRs and describes the major problems that delayed their widespread acceptance. Necessary solutions to the problems are presented in this article. The potential benefits of better EHRs could foster widespread acceptance and use of these systems.

Implementation of a pertussis immunization program in a teaching hospital: an argument for federally mandated pertussis vaccination of health care workers.

BACKGROUND: As pertussis disease becomes more common, health care-associated outbreaks have been reported with increasing frequency. Often, these clusters are costly and labor intensive to investigate and contain. It is clear that health care workers are among the adults who transmit pertussis to susceptible infants. Recent focus on patient safety, together with a concern for protecting employees in the workplace and those they expose elsewhere, has spurred interest in optimizing measures to prevent infection and disease transmission. Shortly after a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed booster was licensed and became available, we designed, launched, and analyzed a campaign to immunize the employees of our institution against pertussis. METHODS: To optimize acceptance of a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed booster by employees, we adopted a program consisting of a 3-phase publicity and educational model and a 3-phase vaccine delivery approach. RESULTS: Despite extraordinary resources dedicated to this program, and our institution's better than average annual uptake of influenza vaccine, less than one third of our eligible employees were immunized. A significant number of employees declined to be vaccinated for inappropriate reasons. CONCLUSION: A campaign of this kind is quite labor intensive and expensive, yet limited overall vaccine uptake was achieved. A federal mandate to require pertussis immunization of all health care workers appears to be a more effective way to protect our patients, employees, families, and society.

Live viral vaccines in the control of highly infectious diseases: measles and varicella.

It is possible that by the end of this decade, measles and varicella two of the most infections and previously universal diseases of children, with massive levels of morbidity and significant mortality, may become of historical interest only. To accomplish this success, it is imperative that all involved parties do what is required. The vaccine supply must be assured, parents must be appropriately educated and reinforced by the media to bring their children to be immunized, and healthcare personnel must both aggressively ascertain and administer needed immunizations.

A case of severe monkeypox virus disease in an American child: emerging infections and changing professional values.

Monkeypox virus disease is a rare zoonosis that until recently was limited to Central Africa. We describe the clinical features of the third child in the United States reported with this newly emerging infection. This child was part of a large cluster of individuals in the Midwest infected by prairie dogs that had contracted the virus when housed with infected small mammals imported from Africa. The differential and laboratory diagnoses and the difficulty finding physicians and nurses to care for this patient are discussed.