Seasonal Variation in Human Adenovirus Conjunctivitis: A 30-Year Observational Study

Seasonality of respiratory, enteric, and urinary viruses revealed by wastewater genomic surveillance

Wastewater surveillance can reveal population-level infectious disease burden and emergent public health threats can be reliably assessed through wastewater surveillance. While molecular methods for wastewater monitoring of microorganisms have traditionally relied on PCR-based approaches, next-generation sequencing (NGS) can provide deeper insights via genomic analyses of multiple diverse pathogens. We conducted a year-long sequencing surveillance of 1,408 composite wastewater samples collected from 12 neighborhood-level access points in the greater Tempe area, Arizona, USA, and show that variation in wastewater viruses is driven by seasonal time and location. The temporal dynamics of viruses in wastewater were influenced cyclically, with the most dissimilarity between samples 23 weeks apart (i.e., winter vs summer, spring vs fall). We identified diverse urinary and enteric viruses including polyomaviruses, astroviruses, and noroviruses, and showed that their genotypes/subtypes shifted across seasons. We show that while wastewater data of certain respiratory viruses like severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) strongly correlate with clinical case rates, laboratory-reported case incidences were discordant with surges of high viral load in wastewater for other viruses like human coronavirus 229E. These results demonstrate the utility of wastewater sequencing for informing decision-making in public health.IMPORTANCEWastewater surveillance can provide insights into the spread of pathogens in communities. Advances in next-generation sequencing (NGS) methodologies allow for more precise detection of viruses in wastewater. Long-term wastewater surveillance of viruses is an important tool for public health preparedness. This system can act as a public health observatory that gives real-time early warning for infectious disease outbreaks and improved response times.

Pathogen Surveillance for Acute Infectious Conjunctivitis

Importance

Acute infectious conjunctivitis is a common ocular condition with major public health consequences.

Objective

To assess regional variations and microbial etiologies of acute infectious conjunctivitis to guide treatment.

Design, Setting, and Participants

In this cross-sectional study, patients with presumed acute infectious conjunctivitis were enrolled in the study at 5 sites (Honolulu, Hawaii; Los Angeles, San Francisco, and San Diego, California; and Petah-Tikva, Israel) from March 2021 to March 2023. Patients with allergic or toxic conjunctivitis were excluded.

Main Outcomes and Measures

Pathogens were identified by unbiased RNA deep sequencing.

Results

In all, 52 patients (mean [range] age, 48 [7-80] years; 31 females [60%]) were enrolled at 5 sites (6 patients from Honolulu, 9 from San Diego, 11 from Los Angeles, 13 from San Francisco, and 13 from Petah-Tikva). RNA deep sequencing detected human adenovirus species D in one-quarter of patients (13 of 52). A wide range of pathogens, including human coronavirus 229E, SARS-CoV-2, and herpes simplex virus type 1, was also identified, as well as several bacteria and fungi. Moreover, 62% (32 of 52) of patients presented with purulent discharge, while only 8% (4 of 52) of patients had confirmed bacterial pathogens.

Conclusion and Relevance

In this cross-sectional study, pathogens associated with acute infectious conjunctivitis varied between all 5 sites in the US and Israel. Purulent discharge was a common presenting sign in this study, with a low specificity for bacteria-associated conjunctivitis, suggesting that further diagnostic workup may be necessary to inform antibiotic stewardship. Additional research on cost-effectiveness of using RNA deep sequencing is needed to ascertain whether it is better to monitor patients clinically until resolution of disease.

TFOS lifestyle: Impact of societal challenges on the ocular surface

Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.

Changes in mean and variance of ophthalmic disease incidences during COVID-19 pandemic in Korea

This study undertook to determine the changes in the numbers of outpatient visits for various ophthalmic diseases during the COVID-19 pandemic compared with before. The monthly outpatient visits for 14 common ophthalmic diseases were enumerated based on the ICD-10 codes in Korean National Health Insurance Service data. The differences in the mean outpatient visits and disease variance 'before' and 'during COVID-19' were calculated. Subsequently, subgroup analyses according to age and sex were performed. The number of outpatient visits for conjunctivitis, scleritis & episcleritis, keratitis, cataract, diabetic retinopathy, and traumatic ophthalmic disease were lower during than before COVID-19 (all P < 0.001). The lower numbers of outpatient visits for ophthalmic disorders during COVID-19 were consistent across the age and sex subgroups. All ophthalmic diseases other than endophthalmitis showed no change of variation 'during' relative to 'before' COVID-19. In conclusion, during the COVID-19 pandemic, the ophthalmic outpatient visits decreased for infectious and inflammatory diseases, screening diseases, and traumatic diseases. However, COVID-19 is not considered to have had a significant effect on variation.

Effect of COVID-19-Related Interventions on the Incidence of Infectious Eye Diseases: Analysis of Nationwide Infectious Disease Incidence Monitoring Data

Objective: Social distancing has been confirmed to reduce the incidence of not only the COVID-19, but also the incidence of other diseases. Therefore, this study aimed to investigate the effect of social distancing policies on the incidence of infectious eye diseases by monitoring their nationwide incidence data in all age groups.

Methods: In this study, to analyse the impact of COVID-19 policy on IEDSC, the time periods were divided into two interventions. The first intervention was the first COVID-19 patient report in Korea on 19 January 2020. The second intervention was relaxation of the social distancing policy on 6 May 2020. Segmented regression analysis of the interrupted time series was used to assess COVID-19 policies on the IEDSC.

Results: After the first incidence of a COVID-19 patient, IEDSCs decreased significantly in all age groups, while the relaxation of the social distancing policy increased IEDSCs significantly, mostly in all groups.

Conclusion: In the post-COVID-19 era, we hope that national-level interventions such as reducing air pollution and employing precautionary measures will significantly reduce the financial burden of developing infectious ophthalmic diseases.

Topical pharmacologic interventions versus placebo for epidemic keratoconjunctivitis

BACKGROUND

Viruses cause about 80% of all cases of acute conjunctivitis. Human adenoviruses are believed to account for 65% to 90% of cases of viral conjunctivitis, or 20% to 75% of all causes of infectious keratoconjunctivitis worldwide. Epidemic keratoconjunctivitis (EKC) is a highly contagious subset of adenoviral conjunctivitis that has been associated with large outbreaks at military installations and at medical facilities. It is accompanied by severe conjunctival inflammation, watery discharge, and light sensitivity, and can lead to chronic complications such as corneal and conjunctival scarring with discomfort and poor quality of vision. Due to a lack of consensus on the efficacy of any pharmacotherapy to alter the clinical course of EKC, no standard of care exists, therefore many clinicians offer only supportive care.

OBJECTIVES

To assess the efficacy and safety of topical pharmacological therapies versus placebo, an active control, or no treatment for adults with EKC.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 4); Ovid MEDLINE; Ovid Embase; Latin American and Caribbean Health Sciences database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), with no restrictions on language or year of publication. The date of the last search was 27 April 2021.

SELECTION CRITERIA

We included randomized controlled trials in which antiseptic agents, virustatic agents, or topical immune-modulating therapy was compared with placebo, an active control, or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology.

MAIN RESULTS

We identified 10 studies conducted in Asia, Europe, the Middle East, and North Africa with a total of 892 participants who were treated for 7 days to 6 months and followed for 7 days up to 1.5 years. Study characteristics and risk of bias In most studies participants were predominantly men (range: 44% to 90%), with an age range from 9 to 82 years. Three studies reported information on trial registration, but we found no published study protocol. The majority of trials had small sample sizes, ranging from 18 to 90 participants enrolled per study; the only exception was a trial that enrolled 350 participants. We judged most studies to be at high or unclear risk of bias across risk of bias domains. Findings We included 10 studies of 892 EKC participants and estimated combined intervention effects in analyses stratified by steroid-containing control treatment or artificial tears. Six trials contributed to the comparisons of topical interventions (povidone-iodine [PVP-I], trifluridine, ganciclovir, dexamethasone plus neomycin) with artificial tears (or saline). Very low certainty evidence from two trials comparing trifluridine or ganciclovir with artificial tears showed inconsistent effects on shortening the mean duration of cardinal symptoms or signs of EKC. Low certainty evidence based on two studies (409 participants) indicated that participants treated with PVP-I alone more often experienced resolution of symptoms (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.07 to 1.24) and signs (RR 3.19, 95% CI 2.29 to 4.45) during the first week of treatment compared with those treated with artificial tears. Very low certainty evidence from two studies (77 participants) suggested that PVP-I or ganciclovir prevented the development of subepithelial infiltrates (SEI) when compared with artificial tears within 30 days of treatment (RR 0.24, 95% CI 0.10 to 0.56). Four studies compared topical interventions (tacrolimus, cyclosporin A [CsA], trifluridine, PVP-I + dexamethasone) with topical steroids, and one trial compared fluorometholone (FML) plus polyvinyl alcohol iodine (PVA-I) with FML plus levofloxacin. Evidence from one trial showed that more eyes receiving PVP-I 1.0% plus dexamethasone 0.1% had symptoms resolved by day seven compared with those receiving dexamethasone alone (RR 9.00, 95% CI 1.23 to 66.05; 52 eyes). In two trials, fewer eyes treated with PVP-I or PVA-I plus steroid developed SEI within 15 days of treatment compared with steroid alone or steroid plus levofloxacin (RR 0.08, 95% CI 0.01 to 0.55; 69 eyes). One study found that CsA was no more effective than steroid for resolving SEI within four weeks of treatment (RR 0.84, 95% CI 0.67 to 1.06; N = 88). The evidence from trials comparing topical interventions with steroids was overall of very low level certainty. Adverse effects Antiviral or antimicrobial agents plus steroid did not differ from artificial tears in terms of ocular discomfort upon instillation (RR 9.23, 95% CI 0.61 to 140.67; N = 19). CsA and tacrolimus eye drops were associated with more cases of severe ocular discomfort, and sometimes intolerance, when compared with steroids (RR 4.64, 95% CI 1.15 to 18.71; 2 studies; N = 141). Compared with steroids, tacrolimus did not increase the risk of elevated intraocular pressure (RR 0.07, 95% CI 0 to 1.13; 1 study; N = 80), while trifluridine conferred no additional risk compared to tear substitute (RR 5.50, 95% CI 0.31 to 96.49; 1 study; N = 97). Overall, bacterial superinfection was rare (one in 23 CsA users) and not associated with use of the intervention steroid (RR 3.63, 95% CI 0.15 to 84.98; N = 51). The evidence for all estimates was of low or very low certainty.

AUTHORS' CONCLUSIONS

The evidence for the seven specified outcomes was of low or very low certainty due to imprecision and high risk of bias. The evidence that antiviral agents shorten the duration of symptoms or signs when compared with artificial tears was inconclusive. Low certainty evidence suggests that PVP-I alone resolves signs and symptoms by seven days relative to artificial tears. PVP-I or PVA-I, alone or with steroid, is associated with lower risks of SEI development than artificial tears or steroid (very low certainty evidence). The currently available evidence is insufficient to determine whether any of the evaluated interventions confers an advantage over steroids or artificial tears with respect to virus eradication or its spread to initially uninvolved fellow eyes. Future updates of this review should provide evidence of high-level certainty from trials with larger sample sizes, enrollment of participants with similar durations of signs and symptoms, and validated methods to assess short- and long-term outcomes.

The Prevalence of Bacteria, Fungi, Viruses, and Acanthamoeba From 3,004 Cases of Keratitis, Endophthalmitis, and Conjunctivitis

PURPOSE

The definitive identification of ocular pathogens optimizes effective treatment. Although the types of ocular pathogens are known; there is less definitive information on the prevalence of causative infections including viruses, fungi, and protozoa, which is the focus of this retrospective laboratory review.

METHODS

Data used for laboratory certification were reviewed for the detection of bacteria, viruses, fungi, and protozoa, from patients with infectious keratitis, endophthalmitis, and conjunctivitis. The main outcome parameter was laboratory-positive ocular infection.

RESULTS

The distribution of infectious agents for keratitis (n=1,387) (2004-2018) was bacteria 72.1% (Staphylococcus aureus 20.3%, Pseudomonas aeruginosa 18%, Streptococcus spp. 8.5%, other gram-positives 12.4%, and other gram-negatives 12.9%), Herpes simplex virus 16%, fungi 6.7%, and Acanthamoeba 5.2%. For endophthalmitis, (n=770) (1993-2018), the bacterial distribution was coagulase-negative Staphylococcus 54%, Streptococcus spp. 21%, S. aureus 10%, other gram-positives 8%, and gram-negatives 7%. The distribution for conjunctivitis (n=847) (2004-2018) was Adenovirus 34%, S. aureus 25.5%, Streptococcus pneumoniae 9%, Haemophilus 9%, other gram-negatives 8.8%, other gram-positives 6%, coagulase-negative Staphylococcus 4.5% and Chlamydia 3.2%.

CONCLUSION

An updated monitoring of ocular pathogens creates an awareness of the different infectious etiologies and the importance of laboratory studies. This information can determine treatment needs for infectious ocular diseases.

An outbreak of adenovirus D8 keratoconjunctivitis in Leicester, United Kingdom, from March to August 2019

We report a large epidemic (n = 126) of keratoconjunctivitis predominantly with two lineages of adenovirus (AdV) type D8 in patients seen in eye casualty between march and August 2019. Other AdV species identified by viral sequencing included B, C, and E. Despite various features of more severe eye disease being present, these were not significantly different between the different AdV species, with similar rates of pseudomembrane formation and keratitis observed in patients with AdV species B as for those with AdV species D.

Epidemic Keratoconjunctivitis in India: Trend Analysis and Implications for Viral Outbreaks

Purpose:

To describe the correlation between the temporal pattern of presentation of acute epidemic keratoconjunctivitis (EKC) of presumed adenoviral etiology with meteorological parameters such as environmental temperature, rainfall, humidity, and wind speed.

Methods:

This cross-sectional hospital-based study included 2,408,819 patients presenting between August 2010 and February 2020. Patients with a clinical diagnosis of EKC in at least one eye were included as cases. A smaller cohort of patients with acute (≤1 week) presentation hailing from the district of Hyderabad during the calendar years 2016–2019 was used to perform correlation analysis with the local environmental temperature, rainfall, humidity, and wind speed (data obtained from the Telangana State Development and Planning Society).

Results:

Overall, 21,196 (0.87%) patients were diagnosed with EKC, of which 19,203 (90.6%) patients had acute onset; among which the cohort from the district of Hyderabad included 1,635 (8.51%) patients. The mean monthly prevalence in this cohort was 0.89% with a peak prevalence in April (1.09%). The environmental parameters of rainfall (r² = 0.47/P = 0.0131), humidity (r² = 0.65/P = 0.0014), and wind speed (r² = 0.56/P = 0.0047) were significantly negatively correlated with the temporal pattern of EKC in the population. There was no visible trend or significant correlation seen with temperature (r² = 0.08/P = 0.3793).

Conclusion:

Contrary to popular belief, epidemic viral infections like EKC may not be affected by temperature, but rather by a complex interplay of other environmental factors such as humidity, rainfall, and wind speed. An increase in rainfall, wind speed, and humidity contributes to a lower prevalence of EKC cases during the year.

Epidemiology of pseudomembranous conjunctivitis in a tertiary hospital: A 2-year retrospective study

PURPOSE

To describe the incidence, duration, and complication rate of patients with a clinical diagnosis of pseudomembranous viral conjunctivitis.

METHODS

A retrospective observational study is performed compiling the data of patients diagnosed as pseudomembranous conjunctivitis at the hospital's emergency department from June 2016 to May 2018. Demographic variables, duration of symptoms, and follow-up until resolution of the pseudomembranes and associated complications are collected.

RESULTS

The incidence rate of pseudomembranous conjunctivitis is 3.47/10,000 people-year and 0.123% of emergency department consultations. The incidence of pseudomembranous conjunctivitis is approximately 20% of the total adenoviral conjunctivitis, with similar peak incidence rates and annual distribution. The presence of pseudomembranes shows a mean duration of 7.86 days. In this series of pseudomembranous patients, 38.4% had at least one of the following complications: 16.7% subepithelial infiltrates (IC 13.0%-21.1%), 20.81% corneal erosions (SE 0.0218, IC 16.7%-25.5%), 3.5% filamentary keratitis (SE 0.010, IC 1.8%-6.0%), and 6.1% subtarsal fibrosis (SE 0.128, IC 3.8%-9.1%).

CONCLUSION

To the best of our knowledge, this is the first study to investigate the incidence and rate of complications of pseudomembranous conjunctivitis. Complications occurred in almost 4 out of 10 patients. The mean duration of the follow-up in the ED was higher in patients with any complication compared with non-complicated patients. The high complication rate makes a closely follow-up advisable, until pseudomembrane resolution, to assess possible complications and symptomatic treatment.