Common childhood viral infections

State of the art in pediatric nanomedicines

In recent years, the continuous development of innovative nanopharmaceuticals is expanding their biomedical and clinical applications. Nanomedicines are being revolutionized to circumvent the limitations of unbound therapeutic agents as well as overcome barriers posed by biological interfaces at the cellular, organ, system, and microenvironment levels. In many ways, the use of nanoconfigured delivery systems has eased challenges associated with patient differences, and in our opinion, this forms the foundation for their potential usefulness in developing innovative medicines and diagnostics for special patient populations. Here, we present a comprehensive review of nanomedicines specifically designed and evaluated for disease management in the pediatric population. Typically, the pediatric population has distinguishing needs relative to those of adults majorly because of their constantly growing bodies and age-related physiological changes, which often need specialized drug formulation interventions to provide desirable therapeutic effects and outcomes. Besides, child-centric drug carriers have unique delivery routes, dosing flexibility, organoleptic properties (e.g., taste, flavor), and caregiver requirements that are often not met by traditional formulations and can impact adherence to therapy. Engineering pediatric medicines as nanoconfigured structures can potentially resolve these limitations stemming from traditional drug carriers because of their unique capabilities. Consequently, researchers from different specialties relentlessly and creatively investigate the usefulness of nanomedicines for pediatric disease management as extensively captured in this compilation. Some examples of nanomedicines covered include nanoparticles, liposomes, and nanomicelles for cancer; solid lipid and lipid-based nanostructured carriers for hypertension; self-nanoemulsifying lipid-based systems and niosomes for infections; and nanocapsules for asthma pharmacotherapy.

Measles in children: a re-emergence of the vaccine-preventable disease

Despite the availability of a safe and effective vaccine, measles remains an endemic in many countries and is the main cause of morbidity and mortality among young children. Therefore, the main objective of this study was to describe the most important aspects of measles that allow clinicians to identify suspected cases for timely diagnosis and treatment, which are essential to avoid inappropriate interventions and prevent complications. The measles virus is highly contagious, is transmitted through fomites and respiratory secretions, and remains active in the environment or on surfaces for several hours. Diagnosing measles can be difficult because most clinicians are unfamiliar as there have been few confirmed cases in recent years. Taking a complete medical history, while considering the clinical phases of measles, and a thorough physical examination can help guide the diagnosis, as the main characteristics of measles (fever and rash) can be seen in both infectious and non-infectious diseases. Treatment consists of three fundamental aspects: supportive care (management of fever and hydration), identification and treatment of associated complications, and prevention of disease spread through patient and family group education. It is important to ensure compliance with immunization policies and strategies globally to control the re-emergence of measles and increase in the burden of disease caused by the measles virus.

Hospital Admission Trends Due to Viral Infections Characterised by Skin and Mucous Membrane Lesions in the Past Two Decades in England and Wales: An Ecological Study

Objectives: This study aimed to investigate the trends in hospital admissions due to viral infections characterized by skin and mucous membrane lesions in England and Wales between 1999 and 2019. Methods: This is an ecological study using publicly available databases in England and Wales; the Hospital Episode Statistics database in England and the Patient Episode Database for Wales. Hospital admissions data were collected for the period between April 1999 and March 2019. Hospital admissions due to viral infections characterized by skin and mucous membrane lesions were identified using the tenth version of the International Statistical Classification of Diseases system, diagnostic codes B00–B09. The trend in hospital admissions was assessed using a Poisson model. Results: Hospital admissions for different causes increased by 51.9% (from 25.67 (95% CI 25.23–26.10) in 1999 to 38.98 (95% CI 38.48–39.48) in 2019 per 100,000 persons, trend test, p < 0.01). The most prevalent viral infections characterized by skin and mucous membrane lesions hospital admissions causes were zoster (herpes zoster), varicella (chickenpox), herpesviral (herpes simplex) infections, and viral warts, which accounted for 26.9%, 23.4%, 18.7%, and 17.6%, respectively. The age group below 15 years accounted for 43.2% of the total number of admissions. Females contributed to 50.5% of the total number of admissions. Hospital admission rate in males increased by 61.1% (from 25.21 (95% CI 24.59–25.82) in 1999 to 40.60 (95% CI 39.87–41.32) in 2019 per 100,000 persons). The increase in females was 43.2% (from 26.11 (95% CI 25.49–26.72) in 1999 to 37.40 (95% CI 36.70–38.09) in 2019 per 100,000 persons). Conclusion: Our study demonstrates an evident variation in hospital admission of viral infections characterized by skin and mucous membrane lesions based on age and gender. Efforts should be directed towards vaccinating high-risk groups, particularly the elderly and females. Moreover, efforts should be focused on vaccinating the young population against varicella, particularly females who are more susceptible to acquiring the infection. Further observational and epidemiological studies are needed to identify other factors associated with increased hospital admission rates.

Current Status of Pediatric Formulations for Chronic and Acute Children' Diseases: Applications and Future Perspectives

Infants and other children can be affected by various acute, chronic and many of them rare illnesses. Developing drugs for children is very challenging since they cannot intake tablets or hard oral solid dosage forms. Besides, most of the prescribed pediatric medications are unlicensed. The biggest issue that clinicians have to solve is that dosing in children is not based on weight or surface area of the body, as it happened in adults but is related to age variations in drug absorption, distribution, metabolism, and elimination. Thus, for pediatric patients, various therapeutic approaches have been proposed so as to develop suitable formulations such as liquid dosage forms, flexible capsules, milk-based products, etc. In addition, the administration of current pharmaceutical products to children might lead to some serious side effects which can also happen in adults but with a lower risk. Especially, infants are at high risk of getting poisoned by taking drugs used for adults. Moreover, children are very sensitive to the taste and smell of some pharmaceutical vehicles and can resist to intake them and this situation leads parents to search for tasteless and odorless medications. In this study, the current formulations for various diseases intended to be used in pediatric patients as well as various chronic and acute diseases of childhood are summarized. Authors believe that this review can help professionals who want to work with pediatric formulations to design more efficient and child-friendly drug delivery systems.

Clinical Significance of Positive Results of the BioFire Cerebrospinal Fluid FilmArray Meningitis/Encephalitis Panel at a Tertiary Medical Center in the United States

CONTEXT.—

The FilmArray Meningitis/Encephalitis (ME) panel is the first US Food and Drug Administration-cleared multiplex polymerase chain reaction panel for the detection of central nervous system infections. While the assay's performance characteristics have been described, the real-world significance of positive results has not been fully characterized.

OBJECTIVE.—

To evaluate the clinical significance of positive ME panel results in a tertiary care medical center in New York, New York.

DESIGN.—

Four physicians independently performed retrospective clinical assessments of all positive ME panel results at Columbia University Irving Medical Center, including the Children's Hospital of New York, during an 18-month period. Each reviewer determined the likelihood of central nervous system infection for all cases and whether cases fit Brighton diagnostic criteria for meningitis, encephalitis, or meningoencephalitis.

RESULTS.—

Among 119 cases, there was 75% positive agreement (95% CI, 54%-89%) between ME panel results and clinical consensus, which varied among panel targets.

CONCLUSIONS.—

The ME panel showed good agreement with expert clinical consensus for patients presenting with acute meningitis/encephalitis. Factors contributing to clinically insignificant ME positive results included low pretest probability, traumatic lumbar puncture, specimen contamination, and detection of incidental viral targets such as human herpesvirus 6. Notably, the ME panel detected more than twice the number of cases of bacterial meningitis detected by culture alone, particularly among patients receiving empiric antimicrobial therapy before lumbar puncture. Appropriate test use and contextual interpretation of results are critical to leveraging the advantages of the platform while avoiding potential pitfalls.

Quality evaluation of molecular diagnostic tests for astrovirus, sapovirus and poliovirus: A multicenter study

BACKGROUND

Astrovirus (AstV), Sapovirus (SaV) and Poliovirus (PV) are important pathogens that cause infections in children under five years of age. It is a very important task to systematically monitor and evaluate the diagnostic performance of these viruses in clinical laboratories.

METHODS

In our study, we performed a multicenter evaluation study among 21 laboratories across China using simulated stool samples spiked with self-designed AstV, SaV and PV pseudoviral particles.

RESULTS

The testing capability of 80.0% (16/20, AstV), 52.6% (10/19, SaV), and 25.0% (2/8, PV) of the participating laboratories were found to be "competent" in reporting correct results for all samples. The main type of errors were false negatives. None of the laboratories identified the subtypes of AstV and SaV, and six laboratories specifically identified the subtypes of PV. Lacking of well-trained personnel and adequate funding were the main challenges. From the questionnaire results, 55.6% laboratories (10/18) believe that training personnel could improve the laboratory testing performance.

CONCLUSIONS

The laboratories showed a competent diagnostic performance for AstV, but inferior diagnostic performances for SaV and PV. Sensitivity of detection and the ability for virus typing should be improved clinically. Professional and standardized personnel training is urgently needed to further improve laboratory performance.

Congenital Rubella Syndrome Surveillance in South Africa Using a Sentinel Site Approach: A Cross-sectional Study

Background

Congenital rubella syndrome (CRS) includes disorders associated with intrauterine rubella infection. Incidence of CRS is higher in countries with no rubella-containing vaccines (RCV) in their immunization schedules. In the World Health Organization African region, RCVs are being introduced as part of the 2012–2020 global measles and rubella strategic plan. This study aimed to describe the epidemiology of confirmed CRS in South Africa prior to introduction of RCVs in the immunization schedule.

Methods

This was a descriptive study with 28 sentinel sites reporting laboratory-confirmed CRS cases in all 9 provinces of South Africa. In the retrospective phase (2010 to 2014), CRS cases were retrieved from medical records, and in the prospective phase (2015 to 2017) clinicians at study sites reported CRS cases monthly.

Results

There were 42 confirmed CRS cases in the retrospective phase and 53 confirmed CRS cases in the prospective phase. Most frequently reported birth defects were congenital heart disease and cataracts. The median age of mothers of CRS cases was 21 years in the retrospective phase (range: 11 to 38 years) and 22 years in the prospective phase (range: 15 to 38 years).

Conclusion

Baseline data on laboratory-confirmed CRS will enable planning and monitoring of RCV implementation in the South African Expanded Programme on Immunization program. Ninety-eight percent of mothers of infants with CRS were young women 14–30 years old, indicating a potential immunity gap in this age group for consideration during introduction of RCV.

Rubella Vaccine Introduction in the South African Public Vaccination Schedule: Mathematical Modelling for Decision Making

Background: age structured mathematical models have been used to evaluate the impact of rubella-containing vaccine (RCV) introduction into existing measles vaccination programs in several countries. South Africa has a well-established measles vaccination program and is considering RCV introduction. This study aimed to provide a comparison of different scenarios and their relative costs within the context of congenital rubella syndrome (CRS) reduction or elimination. Methods: we used a previously published age-structured deterministic discrete time rubella transmission model. We obtained estimates of vaccine costs from the South African medicines price registry and the World Health Organization. We simulated RCV introduction and extracted estimates of rubella incidence, CRS incidence and effective reproductive number over 30 years. Results: compared to scenarios without mass campaigns, scenarios including mass campaigns resulted in more rapid elimination of rubella and congenital rubella syndrome (CRS). Routine vaccination at 12 months of age coupled with vaccination of nine-year-old children was associated with the lowest RCV cost per CRS case averted for a similar percentage CRS reduction. Conclusion: At 80% RCV coverage, all vaccine introduction scenarios would achieve rubella and CRS elimination in South Africa. Any RCV introduction strategy should consider a combination of routine vaccination in the primary immunization series and additional vaccination of older children.

Outcome of upper respiratory tract infections in healthy children: Antibiotic stewardship in treatment of acute upper respiratory tract infections

Objective

The objective of the study was to assess the outcome of upper respiratory tract infections (URTI) in healthy children.

Methods

This descriptive study was conducted on 314 children aged 3-36 months in the paediatric outpatient clinic and emergency department with symptoms of URTI (fever, cough, rhinorrhoea) for ≤5 days. Patient's demographics, clinical features, laboratory data and outcome were recorded. Follow up phone calls were made to parents on day 7 (response 93.6%) and day 14 (response 94.6%) to record outcome.

Results

A total of 314 children with URTIs were included. Majority (57.6%) were males and <1year of age (40%). Common manifestations of URTI were fever (89%), cough (79%), rhinorrhoea (62%), pharyngitis (79%) and conjunctivitis (46%). More than half (53%) had history of contact with URTI in a family member. Mean duration of symptoms was 2.7±1.3 days. Majority (93%) of children were given supportive treatment and only 6.7% received antibiotics initially. Most of children (76%) recovered within one week and 91.8% within two weeks with supportive care only. Only 4% children were hospitalized and 12% required follow up visit of which 16% needed oral antibiotics. Complications or deaths did not occur.

Conclusions

Majority of URTIs in healthy children resolved with supportive treatment and do not require antibiotics. Antibiotic stewardship in simple URTIs should be practiced using awareness and advocacy campaigns.

[Erythrovirus B19 infections. Six years of follow-up in adults and children]

INTRODUCTION

The aetiological agent of erythema infectiosum is Erythrovirus B19 (also known as parvovirus B19), frequently found in children and adolescents, but also associated with arthropathy, aplastic crisis, and abortion in adults.

MATERIAL AND METHODS

A retrospective study of Erythrovirus B19 cases in the years 2010-2015.

RESULTS

Of the 56 cases of Erythrovirus B19 diagnosed, 34 were adults (32 women and 2 men) and 22 younger than 18 years (12 girls and 10 boys). Six cases were in pregnant women. Infections mainly occurred between spring and summer. In childhood, fever (64%), rash (50%), and anaemia (55%) were the most frequent symptoms. However, arthralgia (59%) was the most frequent symptom in adults, and less frequent were anaemia (41%), fever (32%), and rash (29%).

CONCLUSIONS

The characteristic clinical presentation in childhood was rash and fever, whereas in adults it was arthralgia. Anaemia is also frequent, but only severe in previous haematological disease. It should be pointed out that Erythrovirus B19 infection during pregnancy could severely affect the foetus.

Viral Sepsis in Children

Sepsis in children is typically presumed to be bacterial in origin until proven otherwise, but frequently bacterial cultures ultimately return negative. Although viruses may be important causative agents of culture-negative sepsis worldwide, the incidence, disease burden and mortality of viral-induced sepsis is poorly elucidated. Consideration of viral sepsis is critical as its recognition carries implications on appropriate use of antibacterial agents, infection control measures, and, in some cases, specific, time-sensitive antiviral therapies. This review outlines our current understanding of viral sepsis in children and addresses its epidemiology and pathophysiology, including pathogen-host interaction during active infection. Clinical manifestation, diagnostic testing, and management options unique to viral infections will be outlined.

Physical symptoms in very young children assessed for sexual abuse: a mixed method analysis from the ASAC study

So far, a recognizable pattern of clinical symptoms for child sexual abuse (CSA), especially in young male children, is lacking. To improve early recognition of CSA, we reviewed physical complaints, physical examination, and tests on sexually transmitted infections (STIs) in confirmed victims (predominantly preschool boys) of CSA from the Amsterdam sexual abuse case (ASAC). We retrospectively analyzed the outcomes of the primary assessment using mixed methods: descriptive analysis of physical complaints, physical exams, and STI tests from medical files and a qualitative analysis on expert's interpretations of physical complaints and children's behavior during physical examination. We included 54 confirmed CSA victims, median age 3.2 (0-6) years, 43 boys (80%), and 11 girls (20%). Physical complaints were reported in 50%, of which gastrointestinal and anogenital complaints were most common. None of the children showed CSA-specific genital signs at physical examination. Most prominent finding during physical examination was a deviant behavioral response (anxiety, withdrawal, too outgoing) in 15 children (28%), especially in children who experienced anal/vaginal penetration. Testing for STIs was negative.

CONCLUSION

Physical complaints and physical signs at examinations were non-specific for CSA. Deviant behavioral reactions during physical examination were the most prominent finding. Precise observation of a child's behavior during physical examination is needed. What is known • Child sexual abuse (CSA) affects many children on both the short and the long term but remains unrecognized in most cases. • So far, there is a lack of studies on symptom patterns of CSA in male, preschool children. What is new • None of the children showed CSA-specific findings at physical and anogenital examination; STIs were not found in the confirmed victims of CSA. • The most prominent finding was the deviant behavioral response of the children examined, especially in children who experienced anal/vaginal penetration; therefore, precise observation of a child's behavior during physical examination is a crucial part of the evaluation of suspected CSA.

Essentials of infection prevention in the pediatric population

Application of infection prevention and control (IP&C) measures is synonymous with safety, quality, resource saving, and the rights of all patients, staff and visitors. An extensive literature review was undertaken to identify key IP&C measures that address pediatric-specific requirements, taking into account age-related factors, diseases that occur most frequently among pediatric populations, and the important role of the caregiver in prevention and disease transmission. IP&C initiatives that target and incorporate both human (intrinsic) and environmental (extrinsic) sources of infection are population specific and guide practices and provide safe caring environments when used appropriately.

Categories of care specifically geared to the pediatric age-group (0–14 years) are divided into two categories: within-the-healthcare system and outside-of-the-healthcare setting. By taking into account the child's developmental age; physiological, psycho-social and immunological development; differing impacts on the body's natural defense mechanisms, including procedural, device type and length of utilization; and availability of specific technologies and disciplines, the caregiver IP&C strategies can be developed and tailored to address specific needs. Within-the-healthcare setting strategies focus on surveillance, standard and transmission-based precautions, the immune system, age-related factors, institutional regulations, the family and visitation. Outside the healthcare setting preventative and protective measures are vital for providing maximum and comprehensive care. Care provided within and outside the healthcare setting can either be independent of each other or work together to maximize the health and safety of the child.

This review article highlights the importance of IP&C knowledge, need for strict adherence to approved standards, and need for auditing compliance to achieve the ultimate goal of providing safe, quality care as well as an infection-free environment.

Intestinal Targeting of Ganciclovir Release Employing a Novel HEC-PAA Blended Lyomatrix

A hydroxyethylcellulose-poly(acrylic acid) (HEC-PAA) lyomatrix was developed for ganciclovir (GCV) intestine targeting to overcome its undesirable degradation in the stomach. GCV was encapsulated within the HEC-PAA lyomatrix prepared by lyophilization. Conventional tablets were also prepared with identical GCV concentrations in order to compare the GCV release behavior from the lyomatrix and tablets. GCV incorporation (75.12%) was confirmed using FTIR, DSC, and TGA. The effect of GCV loading on the microstructure properties of the lyomatrix was evaluated by SEM, AFM, and BET surface area measurements. The in vitro drug release study showed steady and rapid release profiles from the GCV-loaded lyomatrix compared with the tablet formulation at identical pH values. Minimum GCV release was observed at acidic pH (≤40%) and maximum release occurred at intestinal pH values (≥90%) proving the intestinal targeting ability of the lyomatrix. Kinetic modeling revealed that the GCV-loaded lyomatrix exhibited zero-order release kinetics (n = 1), while the tablets were best described via the Peppas model. Textural analysis highlighted enhanced matrix resilience and rigidity gradient (12.5%, 20 Pa) for the GCV-loaded lyomatrix compared to the pure (7%, 9.5 Pa) HEC-PAA lyomatrix. Bench-top MRI imaging was used to confirm the mechanism of GCV release behavior by monitoring the swelling and erosion rates. The swelling and erosion rate of the tablets was not sufficient to achieve rapid zero-order GCV release as with the lyomatrix. These combined results suggest that the HEC-PAA lyomatrix may be suitable for GCV intestinal targeting after oral administration.

Herpesvirus Infections and Childhood Arterial Ischemic Stroke: Results of the VIPS Study

BACKGROUND

Epidemiological studies demonstrate that childhood infections, including varicella zoster virus, are associated with an increased risk of arterial ischemic stroke (AIS). Other herpesviruses have been linked to childhood AIS in case reports. We sought to determine whether herpesvirus infections, which are potentially treatable, increase the risk of childhood AIS.

METHODS AND RESULTS

We enrolled 326 centrally confirmed cases of AIS and 115 stroke-free controls with trauma (29 days to 18 years of age) with acute blood samples (≤3 weeks after stroke/trauma); cases had convalescent samples (7-28 days later) when feasible. Samples were tested by commercial enzyme-linked immunosorbent assay kits for immunoglobulin M/immunoglobulin G antibodies to herpes simplex virus 1 and 2, cytomegalovirus, Epstein-Barr virus, and varicella zoster virus. An algorithm developed a priori classified serological evidence of past and acute herpesvirus infection as dichotomous variables. The median (quartiles) age was 7.7 (3.1-14.3) years for cases and 10.7 (6.9-13.2) years for controls (P=0.03). Serological evidence of past infection did not differ between cases and controls. However, serological evidence of acute herpesvirus infection doubled the odds of childhood AIS, even after adjusting for age, race, and socioeconomic status (odds ratio, 2.2; 95% confidence interval, 1.2-4.0; P=0.007). Among 187 cases with acute and convalescent blood samples, 85 (45%) showed evidence of acute herpesvirus infection; herpes simplex virus 1 was found most often. Most infections were asymptomatic.

CONCLUSIONS

Herpesviruses may act as a trigger for childhood AIS, even if the infection is subclinical. Antivirals like acyclovir might have a role in the prevention of recurrent stroke if further studies confirm a causal relationship.

Measles outbreaks: what does it represent for the elimination strategy in the region of the Americas? A call for the action

The US is experiencing a large multi-state measles outbreak that started in California in 2014. At this time, no source case for the outbreak has been identified. Measles was declared eliminated in the US in 2000, because at that time, there were high coverage rates with the two-dose schedule and these vaccines have been very immunogenic. Measles is still endemic in many parts of the world, and outbreaks can occur when unvaccinated groups are exposed to imported measles virus. The current multi-state outbreak underscores the ongoing risk of measles importation, the need for high measles vaccination coverage rates, and the importance of a prompt and appropriate public health response to individual cases and outbreaks. The US outbreak threatens measles control in the Americas. Strengthening immunization programs and keeping vaccination coverage rates above 95% with a two-dose schedule will be necessary for measles control strategies in the Americas.