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Yun HC, Young AN, Caballero MY, Lott L, Cropper TL, Murray CK. Changes in Clinical Presentation and Epidemiology of Respiratory Pathogens Associated With Acute Respiratory Illness in Military Trainees After Reintroduction of Adenovirus Vaccine. Open Forum Infect Dis 2015; 2:ofv120. [PMID: 26380351 PMCID: PMC4569648 DOI: 10.1093/ofid/ofv120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 08/17/2015] [Indexed: 01/01/2023] Open
Abstract
Background. Adenovirus (Ad) has long been the predominant cause of acute respiratory illness (ARI) in military trainees. In 2011, live oral Ad vaccines for serotypes 4 and 7 were reintroduced into US basic military training populations. This study evaluated the impact on clinical presentations and other respiratory pathogens. Methods. The Center for Advanced Molecular Detection at Joint Base San Antonio-Lackland prospectively collects demographic, clinical, and polymerase chain reaction data from respiratory specimens (throat swab and nasal wash) among Air Force trainees presenting for care of ARI. Results. From June 2008 to August 2013, 2660 trainees enrolled and were tested for selected respiratory pathogens. Post-vaccine introduction (VI), reported systemic symptoms were less frequent, including fever (38% vs 94%) and myalgia (37% vs 67%; P < .01). Median temperature and heart rate decreased (98.4 vs 101.3°F, 81 vs 96 beats per minute; P < .01). Ad detection decreased for all Ad (3% vs 68%), Ad4 (1% vs 70%), 7 (0% vs 8%), 14 (0% vs 5%), and 3 (0.1% vs 2%); P < .01). Rhinovirus and cases with no pathogen identified increased in frequency (35% vs 18%, 51% vs 14%; P < .01). Conclusions. Acute respiratory illness in military trainees post-VI is associated with decreased severity of systemic symptoms and reduced fever and heart rate. Marked reductions in frequency of Ad serotypes are seen, including those in the vaccine, with no serotype shift. However, detection of several other respiratory pathogens, most notably rhinovirus, is observed in increasing proportions, and a majority are now undiagnosed clinical syndromes.
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Affiliation(s)
- Heather C. Yun
- San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Adam N. Young
- San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
| | | | - Lisa Lott
- 59MDW/ST Joint Base San Antonio-Lackland
| | | | - Clinton K. Murray
- San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Gautret P, Gray GC, Charrel RN, Odezulu NG, Al-Tawfiq JA, Zumla A, Memish ZA. Emerging viral respiratory tract infections--environmental risk factors and transmission. THE LANCET. INFECTIOUS DISEASES 2014; 14:1113-1122. [PMID: 25189350 PMCID: PMC7106556 DOI: 10.1016/s1473-3099(14)70831-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The past decade has seen the emergence of several novel viruses that cause respiratory tract infections in human beings, including Middle East respiratory syndrome coronavirus (MERS-CoV) in Saudi Arabia, an H7N9 influenza A virus in eastern China, a swine-like influenza H3N2 variant virus in the USA, and a human adenovirus 14p1 also in the USA. MERS-CoV and H7N9 viruses are still a major worldwide public health concern. The pathogenesis and mode of transmission of MERS-CoV and H7N9 influenza A virus are poorly understood, making it more difficult to implement intervention and preventive measures. A united and coordinated global response is needed to tackle emerging viruses that can cause fatal respiratory tract infections and to fill major gaps in the understanding of the epidemiology and transmission dynamics of these viruses.
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Affiliation(s)
- Philippe Gautret
- Assistance Publique Hôpitaux de Marseille, CHU Nord, Pôle Infectieux, Institut Hospitalo-Universitaire Méditerranée Infection, Marseille, France; Aix Marseille Université, Unité de Recherche en Maladies Infectieuses et Tropicales Emergentes (URMITE), Faculté de Médecine, Marseille, France.
| | - Gregory C Gray
- College of Public Health and Health Professions and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Remi N Charrel
- Aix Marseille Université, IRD French Institute of Research for Development, EHESP French School of Public Health, EPV UMR-D 190 "Emergence des Pathologies Virales" and IHU Méditerranée Infection, APHM Public Hospitals of Marseille, Marseille, France
| | - Nnanyelugo G Odezulu
- College of Public Health and Health Professions and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Jaffar A Al-Tawfiq
- Johns Hopkins Aramco Healthcare, and Indiana University School of Medicine, Indiana, USA
| | - Alimuddin Zumla
- Center for Clinical Microbiology, Division of Infection and Immunity, University College London, and NIHR Biomedical Research Center, University College London Hospitals, London, UK
| | - Ziad A Memish
- WHO Collaborating Center for Mass Gathering Medicine Ministry of Health and Al-Faisal University, Riyadh, Saudi Arabia
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Abstract
Non-influenza respiratory virus infections are common worldwide and contribute to morbidity and mortality in all age groups. The recently identified Middle East respiratory syndrome coronavirus has been associated with rapidly progressive pneumonia and high mortality rate. Adenovirus 14 has been increasingly recognized in severe acute respiratory illness in both military and civilian individuals. Rhinovirus C and human bocavirus type 1 have been commonly detected in infants and young children with respiratory tract infection and studies have shown a positive correlation between respiratory illness and high viral loads, mono-infection, viremia, and/or serologically-confirmed primary infection.
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Affiliation(s)
- James J Dunn
- Department of Pathology and Laboratory Medicine, Cook Children's Medical Center, 801 Seventh Avenue, Fort Worth, TX 76104, USA.
| | - Melissa B Miller
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Campus Box 7525, Chapel Hill, NC 27599-7525, USA
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Yun HC, Fugate WH, Murray CK, Cropper TL, Lott L, McDonald JM. Pandemic influenza virus 2009 H1N1 and adenovirus in a high risk population of young adults: epidemiology, comparison of clinical presentations, and coinfection. PLoS One 2014; 9:e85094. [PMID: 24416345 PMCID: PMC3885690 DOI: 10.1371/journal.pone.0085094] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 11/22/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In 2009, pandemic H1N1 influenza virus (2009 H1N1) emerged worldwide, causing morbidity and mortality that disproportionately affected young adults. Upper respiratory infection (URI), largely due to adenovirus, is an endemic cause of morbidity in military training. Whether clinical presentations differ or excess morbidity results from coinfection is unclear. METHODS The Center for Advanced Molecular Detection evaluates epidemiology and rapid diagnostics of respiratory pathogens in trainees with URI. From May 1, 2009, to November 30, 2009, demographic, clinical, and PCR data from throat and nasal specimens for adenovirus and 2009 H1N1 were prospectively collected. RESULTS 375 trainees with URI enrolled and were tested for both adenovirus and 2009 H1N1 by PCR (median age 20; 89% male). Adenovirus PCR was positive in 72% (96% serotype E-4) and 2009 H1N1 in 20%. Males were more likely to have adenovirus and females more likely to have 2009 H1N1 (p = 0.047). Subjects with 2009 H1N1 presented an average of 1 week earlier in training, had shorter illness duration before enrollment, less sore throat, diarrhea, and fewer abnormal findings on throat exam. Coryza and cough were more common with 2009 H1N1 compared to adenovirus. Subjects with 2009 H1N1 were less likely to have adenovirus than those without, despite persistently high frequencies of adenovirus detections during peak 2009 H1N1 weeks (15% vs. 83%, p < 0.01). Coinfection with adenovirus and 2009 H1N1 was rare (4%). Rates of hospitalization and pneumonia did not differ between the adenovirus, 2009 H1N1, or coinfected groups. CONCLUSION Military trainees with 2009 H1N1 vs. adenovirus have differing clinical presentations, and males are more likely to have adenovirus. Despite high frequencies of adenovirus infection, coinfection with adenovirus and 2009 H1N1 is rare and apparently does not result in increased morbidity.
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Affiliation(s)
- Heather C. Yun
- San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas, United States of America
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- * E-mail:
| | - William H. Fugate
- Center for Advanced Molecular Detection, 59th MDW/ST, Joint Base San Antonio-Lackland, Texas, United States of America
| | - Clinton K. Murray
- San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas, United States of America
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Thomas L. Cropper
- Trainee Health Surveillance, Joint Base San Antonio-Lackland, Texas, United States of America
| | - Lisa Lott
- Center for Advanced Molecular Detection, 59th MDW/ST, Joint Base San Antonio-Lackland, Texas, United States of America
| | - J. Matthew McDonald
- Center for Advanced Molecular Detection, 59th MDW/ST, Joint Base San Antonio-Lackland, Texas, United States of America
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Ylihärsilä M, Harju E, Arppe R, Hattara L, Hölsä J, Saviranta P, Soukka T, Waris M. Genotyping of clinically relevant human adenoviruses by array-in-well hybridization assay. Clin Microbiol Infect 2013; 19:551-7. [PMID: 22712766 PMCID: PMC7129513 DOI: 10.1111/j.1469-0691.2012.03926.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A robust oligonucleotide array-in-well hybridization assay using novel up-converting phosphor reporter technology was applied for genotyping clinically relevant human adenovirus types. A total of 231 adenovirus-positive respiratory, ocular swab, stool and other specimens from 219 patients collected between April 2010 and April 2011 were included in the study. After a real-time PCR amplification targeting the adenovirus hexon gene, the array-in-well assay identified the presence of B03 (n = 122; 57.5% of patients), E04 (29; 13.7%), C02 (21; 9.9%), D37 (14; 6.6%), C01 (12; 5.7%), C05 (5; 2.4%), D19 (4; 1.9%), C06 (2; 0.9%), D08 (1; 0.5%), A31 (1; 0.5%) and F41 (1; 0.5%) genotypes among the clinical sample panel. The typing result was obtained for all specimens that could be amplified (n = 223; 97%), and specificity of the typing was confirmed by sequencing specimens representing each of the different genotypes. No hybridization signal was obtained in adenovirus-negative specimens or specimens with other viruses (n = 30). The array-in-well hybridization assay has great potential as a rapid and multiplex platform for the typing of clinically relevant human adenovirus genotypes in different specimen types.
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Affiliation(s)
- M Ylihärsilä
- Department of Virology, University of Turku, Turku, Finland.
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History of the restoration of adenovirus type 4 and type 7 vaccine, live oral (Adenovirus Vaccine) in the context of the Department of Defense acquisition system. Vaccine 2013; 31:1623-32. [DOI: 10.1016/j.vaccine.2012.12.029] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 12/07/2012] [Accepted: 12/10/2012] [Indexed: 11/19/2022]
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Yao J, Flack K, Ding L, Zhong W. Tagging the rolling circle products with nanocrystal clusters for cascade signal increase in the detection of miRNA. Analyst 2013; 138:3121-5. [DOI: 10.1039/c3an00398a] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Anderson BD, Barr KL, Heil GL, Friary JA, Gray GC. A comparison of viral fitness and virulence between emergent adenovirus 14p1 and prototype adenovirus 14p strains. J Clin Virol 2012; 54:265-8. [PMID: 22484030 DOI: 10.1016/j.jcv.2012.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 03/06/2012] [Accepted: 03/08/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Epidemiological studies from the last decade have suggested that the morbidity and mortality associated with a newly emergent strain of human adenovirus (HAdV-14p1) is greater than other, more prevalent, adenovirus strains. Recent molecular analysis identified very minor genetic differences in HAdV-14p1 compared to prototype HAdV-14p. No studies have evaluated how these differences may affect virulence. OBJECTIVE To compare HAdV-14p1 and HAdV-14p strains for competitive fitness and virulence. STUDY DESIGN We performed in vitro and molecular assays to evaluate growth kinetics, cellular infectivity, cytotoxicity, and plaque morphology of the two strains. RESULTS Growth kinetic data showed no viral replication at 30°C and minimal differences at 37°C for both strains. Cellular infectivity data showed propagation capabilities for both strains in a diverse array of cell lines, with human lung and kidney cells having the highest propagation potential. Cytotoxicity data indicated cellular distress differences induced by both strains of virus in the first 12h, but similar distress levels between 12 and 48 h. Plaque morphology assays showed some differences in average plaque diameter. CONCLUSIONS These data suggest that the increase in morbidity and mortality observed in recent HAdV-14p1 infections is not due to viral growth or cellular infectivity differences from the prototypic HAdV-14 strain. While there were some statistically important differences detected between strains in cytotoxicity and plaque morphology assays, it seems more likely that other factors, such as environmental stressors, co-infections, or individual host response are likely contributing to the increase in morbidity.
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Affiliation(s)
- Benjamin D Anderson
- College of Public Health and Health Professions, and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA.
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Sergueev KV, Nikolich MP, Filippov AA. Field and clinical applications of advanced bacteriophage-based detection of Yersinia pestis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 954:135-41. [PMID: 22782756 DOI: 10.1007/978-1-4614-3561-7_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Kirill V Sergueev
- Department of Emerging Bacterial Infections, Division of Bacterial and Rickettsial Diseases, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA.
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Kammerer PE, Montiel S, Kriner P, Bojorquez I, Bejarano Ramirez V, Vazquez-Erlbeck M, Azziz-Baumgartner E, Blair PJ, Hawksworth AW, Faix DJ, Nava ML, Lopez LW, Palacios E, Flores R, Fonseca-Ford M, Phippard A, Lopez K, Johnson J, Bustamante Moreno JG, Russell KL, Waterman SH. Influenza-like illness surveillance on the California-Mexico border, 2004-2009. Influenza Other Respir Viruses 2011; 6:358-66. [PMID: 22212638 PMCID: PMC5779811 DOI: 10.1111/j.1750-2659.2011.00316.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Since 2004, the Naval Health Research Center, with San Diego and Imperial counties, has collaborated with the US Centers for Disease Control and Prevention to conduct respiratory disease surveillance in the US-Mexico border region. In 2007, the Secretariat of Health, Mexico and the Institute of Public Health of Baja California joined the collaboration. OBJECTIVES The identification of circulating respiratory pathogens in respiratory specimens from patients with influenza-like illness (ILI). METHODS Demographic, symptom information and respiratory swabs were collected from enrollees who met the case definition for ILI. Specimens underwent PCR testing and culture in virology and bacteriology. RESULTS From 2004 through 2009, 1855 persons were sampled. Overall, 36% of the participants had a pathogen identified. The most frequent pathogen was influenza (25%), with those aged 6-15 years the most frequently affected. In April 2009, a young female participant from Imperial County, California, was among the first documented cases of 2009 H1N1. Additional pathogens included influenza B, adenovirus, parainfluenza virus, respiratory syncytial virus, enterovirus, herpes simplex virus, Streptococcus pneumoniae, and Streptococcus pyogenes. CONCLUSIONS The US-Mexico border is one of the busiest in the world, with a large number of daily crossings. Due to its traffic, this area is an ideal location for surveillance sites. We identified a pathogen in 36% of the specimens tested, with influenza A the most common pathogen. A number of other viral and bacterial respiratory pathogens were identified. An understanding of the incidence of respiratory pathogens in border populations is useful for development of regional vaccination and disease prevention responses.
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Clinical validation of multiplex real-time PCR assays for detection of bacterial meningitis pathogens. J Clin Microbiol 2011; 50:702-8. [PMID: 22170919 DOI: 10.1128/jcm.06087-11] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae are important causes of meningitis and other infections, and rapid, sensitive, and specific laboratory assays are critical for effective public health interventions. Singleplex real-time PCR assays have been developed to detect N. meningitidis ctrA, H. influenzae hpd, and S. pneumoniae lytA and serogroup-specific genes in the cap locus for N. meningitidis serogroups A, B, C, W135, X, and Y. However, the assay sensitivity for serogroups B, W135, and Y is low. We aimed to improve assay sensitivity and develop multiplex assays to reduce time and cost. New singleplex real-time PCR assays for serogroup B synD, W135 synG, and Y synF showed 100% specificity for detecting N. meningitidis species, with high sensitivity (serogroup B synD, 99% [75/76]; W135 synG, 97% [38/39]; and Y synF, 100% [66/66]). The lower limits of detection (LLD) were 9, 43, and 10 copies/reaction for serogroup B synD, W135 synG, and Y synF assays, respectively, a significant improvement compared to results for the previous singleplex assays. We developed three multiplex real-time PCR assays for detection of (i) N. meningitidis ctrA, H. influenzae hpd, and S. pneumoniae lytA (NHS assay); (ii) N. meningitidis serogroups A, W135, and X (AWX assay); and (iii) N. meningitidis serogroups B, C, and Y (BCY assay). Each multiplex assay was 100% specific for detecting its target organisms or serogroups, and the LLD was similar to that for the singleplex assay. Pairwise comparison of real-time PCR between multiplex and singleplex assays showed that cycle threshold values of the multiplex assay were similar to those for the singleplex assay. There were no substantial differences in sensitivity and specificity between these multiplex and singleplex real-time PCR assays.
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Ganzenmueller T, Heim A. Adenoviral load diagnostics by quantitative polymerase chain reaction: techniques and application. Rev Med Virol 2011; 22:194-208. [PMID: 22162042 DOI: 10.1002/rmv.724] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 10/18/2011] [Accepted: 10/21/2011] [Indexed: 12/19/2022]
Abstract
Human adenoviruses (HAdV) can cause fatal complications such as disseminated disease especially in a post-transplant setting. With conventional methods, disseminated HAdV disease could only be diagnosed with delay. Quantification of the HAdV load by real-time PCR in peripheral blood promised to solve this diagnostic dilemma. Here we review the development, applications and significance of quantitative HAdV PCR. The high genetic divergence of the 56 HAdV types was a major obstacle for developing a quantitative HAdV PCR covering all types. Several protocols focused either on a few, probably predominating types or tried to detect all known HAdV types by using a bundle of assays or a few multiplexed PCRs. Alternatively, generic quantitative real-time HAdV PCR protocols using primer and probe consensus sequences have been designed, providing considerable reduction of costs and hands-on time. Application of HAdV load testing by several studies on stem cell transplant (SCT) recipients indicated that rapidly increasing HAdV blood loads as well as high HAdV DNAemia (e.g. >10(4) copies/ml) are predictive for disseminated HAdV disease although a universal threshold value has not yet been established. HAdV load testing has been implemented for systematic screening of SCT patients permitting early diagnosis, pre-emptive treatment initiation and monitoring of antiviral therapy. However, further investigations are required to validate proposed virus load thresholds. Moreover, other applications of quantitative HAdV PCR, such as the diagnosis of localized HAdV disease, the analysis of environmental samples and monitoring of gene therapy with adenoviral vectors will be addressed in this review.
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Jones MS, Hudson NR, Gibbins C, Fischer SL. Evaluation of type-specific real-time PCR assays using the LightCycler and J.B.A.I.D.S. for detection of adenoviruses in species HAdV-C. PLoS One 2011; 6:e26862. [PMID: 22046386 PMCID: PMC3203158 DOI: 10.1371/journal.pone.0026862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 10/05/2011] [Indexed: 11/23/2022] Open
Abstract
Sporadically, HAdVs from species HAdV-C are detected in acute respiratory disease outbreaks. To rapidly type these viruses, we designed real-time PCR assays that detect and discriminate between adenovirus types HAdV-C1, -C2, -C5, and -C6. Sixteen clinical isolates from the California Department of Public Health were used to validate the new assays. Type-specific TaqMan real-time PCR assays were designed and used independently to successfully identify 16 representative specimens. The lower limit of detection for our LightCycler singleplex real-time PCR assays were calculated to be 100, 100, 100, and 50 genomic copies per reaction for HAdV-C1, HAdV-C2, HAdV-C5 and HAdV-C6, respectively. The results for the singleplex J.B.A.I.D.S. assays were similar. Our assays did not cross-react with other adenoviruses outside of species HAdV-C, respiratory syncytial virus, influenza, or respiratory disease causing bacteria. These assays have the potential to be useful as diagnostic tools for species HAdV-C infection.
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Affiliation(s)
- Morris S Jones
- Viral and Rickettsial Disease Laboratory, California Department of Health Services, Richmond, California, United States of America.
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Abstract
Adenovirus plays a significant role in respiratory tract disease in pediatric and adult patients. It has been linked to outbreaks and epidemics in various patient populations, resulting in considerable morbidity and mortality. In this article, we discuss the epidemiology, pathogenesis, respiratory tract illnesses and complications, and roles of potential treatment options. The role of the past oral adenovirus vaccine and the military implications of its withdrawal from routine use in military recruits is discussed as well.
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Affiliation(s)
- Anjali N Kunz
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20184, USA,
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