Malaria in West Virginia: forty cases seen at West Virginia University Hospital.

In the U.S., malaria predominately occurs in travelers and immigrants. We report a series of 40 cases at West Virginia University Hospital, and 24 of whom were students who had visited areas of East Africa, West Africa and Asia usually in either December, January, August or September. Most patients (79%) reported a previous episode of malaria, and P. falciparum was identified in 60%. Fever, chills and rigors were the most common symptoms. Correct use of malaria prophylaxis was recorded in five patients, and only two of these were students. Successful outcomes were recorded in all but one patient. Our series suggests that international students would benefit from the proper use of chemoprophylaxis, thus decreasing the number of cases of malaria seen in university settings.

The benefits of telephone-access medical consultation.

A major disadvantage of rural medical practice is the limited reserve of consultative options. To determine the perceived clinical utility and educational impact of the West Virginia University Medical Access and Referral System (MARS), a 24-hour prompt telephone-consultation service, a mailed questionnaire was administered to 303 West Virginia clinicians who had used MARS for infectious disease problems. The overall questionnaire response rate was 62 percent. Callers included family practitioners (35%), medical specialists (32%), surgical specialists (13%), pediatricians (11%), obstetricians (5%), and nonphysicians (4%). Major referral questions posed were therapeutic (60%), diagnostic (48%), and epidemiologic (10%) in nature. On a scale of 1 (not useful) to 5 (very useful), survey responders rated the overall clinical usefulness of MARS as either a 4 (22%) or 5 (76%). Callers felt that MARS consultation assisted in accurate case diagnosis in 80 percent of cases, and aided in successful therapeutic management of 96 percent of cases. An educational benefit was reported by 96 percent of responders. Physicians located in more rural, underserved areas tended to use MARS to a greater degree than colleagues in more populated, medically accessible areas (P < 0.005). These findings suggest that an academic telephone-access consultation program can be a clinically relevant and educational consultative tool for practicing clinicians, especially those located in rural areas.

Effect of bedside needle disposal units on needle recapping frequency and needlestick injury.

Needle recapping has been shown to be one of the leading causes of needlestick injuries. Frequency of recapping has not been reported. This study was designed to determine the frequency of needle recapping by nursing personnel and the effect of bedside needle disposal units on the frequency of recapping and needlesticks. Seventy-four nurses carrying out 312 activities involving use of needles were observed. The subjects were not aware of the nature of the study. The recapping frequency was 93.9%. The study was repeated after educational programs and following installation of a hospital-wide bedside needle disposal system. Fifty-three nurses performing 151 activities with needles were observed. Frequency of recapping was 94%. There was no significant difference in the rate of recapping or needlestick injuries after installation of the new needle disposal system. Educational programs regarding recapping, a very common practice, may be ineffective. Alternate methods for preventing needlesticks may be necessary.

Age-dependent antibody response in mice and humans following oral influenza immunization.

In order to compare the antibody response in serum and secretions from healthy young subjects and the elderly (greater than 60 years), volunteers were immunized with the commercial inactivated influenza virus vaccine, by the usual (parenteral) route or orally. Also, young and old mice (mean age, 20 months) were orally immunized with live influenza virus. The older mice responded with a very slight rise in their serum and respiratory tract antibody levels compared with the young mice but showed no diminution in protection against lethal viral challenge. Elderly volunteers showed only slight serum antibody responses after parenteral immunization compared with the young. Neither group demonstrated a rise in serum antibody following oral immunization. With respect to the secretory IgA (SIgA) antibody response, certain differences were noted between the young and the elderly: the preimmunization levels of antibody to influenza virus were significantly greater in nasal secretions and saliva in the elderly as compared to the young volunteers, and the salivary antibody response was diminished in the elderly. This lack of a salivary antibody response in the elderly was explicable by the inverse relationship between the preimmunization SIgA antibody titers and the response to immunization. Oral immunization led to no more side effects than observed in the placebo control group.

Secretory antibody following oral influenza immunization.

Secretory IgA antibody may be important in protection against respiratory viral infections, and the concept of a common mucosal immune system offers the theoretical basis for the convenient stimulation of this antibody. Therefore, the oral route was compared with intramuscular injection in a double-blind, placebo-controlled study in young healthy volunteers. A killed influenza vaccine, given in enteric-coated capsules (total of 98 ug hemagglutinin of A/Bangkok) led to significant salivary and nasal IgA antibody rises in a 4-week period. The preimmunization titers in secretions were inversely correlated with the antibody rise after immunization. The orally administered vaccine was associated with no more side effects than placebo, in contradistinction to reactions following the intramuscular route. The latter route also was without significant effect in regard to a stimulation of secretory antibodies. The observed simultaneous induction of antibodies in saliva and nasal secretions following oral administration of killed vaccine gives further evidence of a common mucosal immune system and its possible clinical use.

Blastomycosis of the esophagus presenting with gastrointestinal bleeding.

A patient with abdominal discomfort and hematemesis was found to have lower esophageal inflammation on endoscopy. A biopsy specimen from this area showed yeast forms of Blastomyces dermatitidis with a polymorphonuclear infiltrate and granuloma formation. Extensive evaluation showed no other bleeding site. Sputum samples obtained earlier also showed B. dermatitidis. Treatment with amphotericin B led to resolution of bleeding and eradication of the fungus on repeat biopsy and sputum samples. An esophageal stricture subsequently developed and required dilation. Seven previously reported cases of esophageal blastomycosis are reviewed.

Immunization against influenza in humans using an oral enteric-coated killed virus vaccine.

By ingestion of subunit-killed influenza virus vaccine in the form of enteric-coated capsules, local synthesis of secretory IgA (sIgA) antibody was stimulated in human nasal secretions. A fairly equal antibody response initiated by oral and intramuscular administration was demonstrated in the nasal secretions, although a systemic immune response was not elicited from ingestion of the vaccine. If the secretory antibody response resulted from absorption of antigen and transport to the respiratory mucosa, systemic (serum) antibody would be expected. Therefore these findings support the hypothesis that specialized collections of lymphoid cells in the small intestines have IgA precursor cells which circulate and populate distant mucosal sites. A number of studies have suggested that protection against mucosal infection by a variety of respiratory viruses correlates better with the presence and level of sIgA antibody than with serum antibody. The orally administered vaccine was associated with no more side effects than placebo, in contradistinction to the intramuscular route. Thus, the oral method of influenza vaccination could prove to be superior in providing for immunological protection due to equal secretory antibody stimulation, improved convenience and less toxicity.

Oral route as method for immunizing against mucosal pathogens.

In the past three decades significant strides have been made in attempts at nonparenteral immunization. Appreciation of the importance of secretory immunity led to attempts to stimulate antibody production locally. The vaccines developed against respiratory pathogens as a result of this new knowledge have many practical limitations, such as the need for highly trained personnel, expensive equipment, very cooperative recipients for intranasal or aerosol administration, and a vaccine that is both adequately attenuated, immunogenic, and stable during storage. With recognition of the presence of a common mucosal defense system, new approaches to vaccine development have become possible. Oral immunization, by stimulating GALT, presents a promising approach for protecting many secretory surfaces against a variety of infectious agents. Recently, emphasis has been placed on developing an oral vaccine against S. mutans. McGhee et al. have demonstrated antibody to S. mutans in saliva and tears following oral ingestion of that antigen, without a rise in serum antibody, in both humans and rats. The rats were afforded protection from caries after rechallenge with both the original and cross-reacting serotypes of S. mutans. Similar results have recently been seen with viral antigens. Mice have been shown to have significant protection against influenza infection following oral immunization. And in a pilot study with human volunteers, the secretory antibody response in nasal washes was similar following either oral or parenteral vaccination. Oral immunization may prove to be far superior to parenteral vaccination against a variety of pathogens, because of fewer side effects and greater ease in vaccine preparation and administration.

Pulmonary function in infectious mononucleosis.

Infectious mononucleosis (IM) is common among students. These patients often complain of fatigue and dyspnea. To determine whether IM alters respiratory function, we performed spirometric, single-breath diffusing capacity, and maximal static respiratory pressure tests on seven patients with symptoms of IM. These studies were repeated two weeks later and the respiratory pressures were repeated five months later. Each patient served as his own control. Pulmonary function was normal except for respiratory pressures, which were initially low. These pressures, still low after two weeks, improved significantly after five months. We concluded that IM is associated with transient respiratory muscle weakness.

Oral immunization against influenza.

An anti influenza vaccine was administered by oral route, as capsules, to 24 volunteers. The presence of IgAs in nasal secretions led us to the fact that some lymphocytes of the small intestine were the precursors of circulating IgAs, and, while proliferating, they settled on mucous sites at a distance.