Laboratory-based surveillance in the molecular era: the TYPENED model, a joint data-sharing platform for clinical and public health laboratories

Laboratory-based surveillance, one of the pillars of monitoring infectious disease trends, relies on data produced in clinical and/or public health laboratories. Currently, diagnostic laboratories worldwide submit strains or samples to a relatively small number of reference laboratories for characterisation and typing. However, with the introduction of molecular diagnostic methods and sequencing in most of the larger diagnostic and university hospital centres in high-income countries, the distinction between diagnostic and reference/public health laboratory functions has become less clear-cut. Given these developments, new ways of networking and data sharing are needed. Assuming that clinical and public health laboratories may be able to use the same data for their own purposes when sequence-based testing and typing are used, we explored ways to develop a collaborative approach and a jointly owned database (TYPENED) in the Netherlands. The rationale was that sequence data - whether produced to support clinical care or for surveillance -can be aggregated to meet both needs. Here we describe the development of the TYPENED approach and supporting infrastructure, and the implementation of a pilot laboratory network sharing enterovirus sequences and metadata.

Severe influenza resembling hemorrhagic shock and encephalopathy syndrome

Influenza-associated encephalopathy is a clinically diverse syndrome and severe cases are not well documented outside Japan. Clinical, pathological and molecular aspects are described of two fatal cases presenting during 2004 and 2005 winter seasons in The Netherlands. Results showed that severe influenza can resemble hemorrhagic shock and encephalopathy syndrome, and proper testing for influenza virus should be considered in similar cases. The failure to detect viral replication in non-pulmonary organs including the brain would support the pathogenesis of this syndrome is based on proinflammatory cytokine responses.

Quantitative detection of herpes simplex virus DNA in the lower respiratory tract

Quantitation of herpes simplex virus (HSV) DNA in bronchoalveolar lavage specimens could indicate an infectious role in the lower respiratory tract. The aim of this study was to compare quantitative HSV DNA results from adult bronchoalveolar lavage specimens to clinical outcome. Quantitative real-time PCR assays targeting HSV and other herpes viruses were performed on adult bronchoalveolar lavage specimens obtained from a largely immunocompromised population during a 1-year period. The results were compared to patient characteristics and outcome. HSV DNA was detected in 11 (19%) of 57 bronchoalveolar lavage specimens with a mean viral level of 5.6 log genome equivalents/ml (range, 2.9-8.1 log). A threshold of HSV DNA levels equal or higher than 5.0 log (n = 7) was associated with mortality within 28 days following hospital admission (odds ratio [OR], 6.8; 95% confidence interval [CI], 1.2-39.2). A threshold level of 5.5 log was associated with mortality within 28 days of sampling (OR 8.5; 95% CI 1.2-62.1), only after excluding patients receiving specific antiviral medication. Patients with HSV DNA levels equal or higher than 7.5 log had severe respiratory failure. Viral pneumonia was histologically proven in one patient with 8.0 log at autopsy. No patient with HSV DNA levels below 5.5 log (n = 5) or DNA levels higher than 5.0 log of cytomegalovirus (CMV) (n = 3), Epstein-Barr virus (EBV) (n = 9), varicella-zoster virus (VZV) (n = 1), or human herpesvirus 6 (HHV-6) (n = 0) died within 28 days of hospital admission. We conclude that quantitative detection of HSV DNA in bronchoalveolar lavage fluid is a potential diagnostic tool for detection of relevant viral infection of the lower respiratory tract.

Evaluation of an internally controlled real-time PCR targeting the ospA gene for detection of Borrelia burgdorferi sensu lato DNA in cerebrospinal fluid

This study reports the development and evaluation of an internally controlled real-time PCR targeting the ospA gene for detection of Borrelia burgdorferi sensu stricto, Borrelia garinii, Borrelia afzelii and Borrelia valaisiana. DNA was extracted using QIAamp DNA Blood Mini kit columns. DNA from 33 B. burgdorferi sensu lato strains reacted in the assay, whereas no reactivity was observed with DNA from four relapsing fever Borrelia spp., 11 unrelated spirochaetes, and 31 unrelated microorganisms. The quantitative sensitivity of the assay was 1-10 fg of Borrelia DNA and one to five cultured Borrelia spirochaetes. Cerebrospinal fluid (CSF) specimens from 70 patients sent for routine testing for neuroborreliosis, and three CSF specimens containing B. garinii were also tested. Positive PCR results were obtained with all three culture-confirmed neuroborreliosis specimens, five of ten neuroborreliosis specimens with specific antibodies in CSF and pleocytosis, none of nine specimens from possible cases of early neuroborreliosis (antibodies in serum, CSF pleocytosis, no antibodies in CSF), one of 15 specimens from patients with active or past Lyme disease with neurological signs (antibodies in serum, no pleocytosis or antibodies in CSF), and none of 36 specimens from patients without Lyme borreliosis (no antibodies in serum or CSF). Overall, the real-time PCR assay enabled sensitive and specific detection of all B. burgdorferi sensu lato species tested. The PCR had a sensitivity of 50% in patients with neuroborreliosis. The main diagnostic role of the assay could be to confirm neuroborreliosis in patients for whom the diagnosis is doubtful.

[From fowl plague to influenza pandemic; a reason for taking precaution]

Throughout Eastern Asia, there is currently an epidemic of fowl plague or highly pathogenic avian influenza, on an unprecedented scale. The prospects for rapid containment are poor. The causative virus, influenza A of the H5N1 subtype, is of limited infectivity for humans. If infection occurs, however, then the consequences are serious and even fatal in a majority of cases. In view of the receptor specificity of avian influenza viruses, this may be related to individually increased susceptibility, which does not lead to further spread. However, it is known that influenza A viruses can readily adapt to replication in the human host by the acquisition of specific gene segments or even by mutations of the avian virus. The extreme scale of human contact with influenza virus of the H5N1 subtype at present engenders fear that there is a high risk of such adaptation and a subsequent pandemic spread. Adequate precautions are necessary, not only in terms of an acceleration of vaccine production but primarily in arranging for sufficient availability of the new antiviral drugs.

Efficient extraction of virus DNA by NucliSens Extractor allows sensitive detection of hepatitis B virus by PCR

The NucliSens Extractor is an automated nucleic acid isolation system based on guanidinium thiocyanate (GuSCN)-silica extraction technology. The system has been validated for the isolation of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) RNAs from human samples in combination with nucleic acid sequence-based amplification- and reverse transcription-PCR-based methods. We evaluated the extractor for hepatitis B virus (HBV) DNA extraction from human samples using a noncommercial HBV DNA PCR. Several sample pretreatment procedures in combination with the extractor were compared with the Qiagen extraction method, and the impact of the sample volume used in the extraction on the sensitivity was investigated. Heating of the lysed sample prior to extractor isolation and the use of a large sample volume resulted in highly sensitive detection of HBV DNA. Incubation of a 1-ml sample in GuSCN at 80 degrees C (10 min) and at 37 degrees C (30 min) allowed detection of 4 and 40 HBV genome equivalents/ml, respectively, in standard dilution panels. Sample lysis in GuSCN at room temperature and proteinase K treatment prior to use of the extractor were less efficient procedures. All clinical samples that were PCR positive after Qiagen extraction and/or that were HBsAg positive were also PCR positive after extractor isolation. HBV DNA, HCV RNA, and HIV type 1 RNA were efficiently coextracted from a single sample, allowing reliable detection of viral genomes.

Antigenic and molecular heterogeneity in recent swine influenza A(H1N1) virus isolates with possible implications for vaccination policy

In order to explore the occurrence of antigenic drift in swine influenza A(H1N1) viruses and the match between epidemic and vaccine strains, 26 virus isolates from outbreaks of respiratory disease among finishing pigs in the Netherlands in the 1995/1996 season and reference strains from earlier outbreaks were examined using serological and molecular methods. In contrast to swine H3N2 viruses, no significant antigenic drift was observed in swine H1N1 viruses isolated from the late 1980s up to 1996 inclusive. However, a marked antigenic and genetic heterogeneity in haemagglutination inhibition tests and nucleotide sequence analyses was detected among the 26 recent swine H1N1 virus strains. Interestingly, the observed antigenic and molecular variants were not randomly distributed over the farms. This finding indicates independent introductions of different swine H1N1 virus variants at the various farms of the study and points to a marked difference between the epidemiologies of human and swine influenza viruses. The observed heterogeneity may hamper the control of swine influenza by vaccination and indicates that the efficacy of current swine influenza vaccines requires re-evaluation and that the antigenic reactivity of swine influenza viruses should be monitored on a regular basis.

Antigenic and genetic characterization of swine influenza A (H1N1) viruses isolated from pneumonia patients in The Netherlands

It is generally believed that pigs can serve as an intermediate host for the transmission of avian influenza viruses to humans or as mixing vessels for the generation of avian-human reassortant viruses. Here we describe the antigenic and genetic characterization of two influenza A (H1N1) viruses, which were isolated in The Netherlands from two patients who suffered from pneumonia. Both viruses proved to be antigenically and genetically similar to avian-like swine influenza A (H1N1) viruses which currently circulate in European pigs. It is concluded that European swine H1N1 viruses can infect humans directly, causing serious disease without the need for any reassortment event.

Prevention and treatment of bronchopneumonia in mice caused by mouse-adapted variant of avian H5N2 influenza A virus using monoclonal antibody against conserved epitope in the HA stem region

The effects of monoclonal antibody (MAb) C179 recognizing a conformational epitope in the middle of the hemagglutinine (HA) stem region were examined in a mouse model in the experiments of prevention and treatment of lethal bronchopneumonia caused by influenza A virus of H5 subtype. To model the lethal infection, avian nonpathogenic strain A/mallard duck/Pennsylvania/10218/84 (H5N2) was adapted to mice. This resulted in highly pathogenic pneumovirulent mouse-adapted (MA) variant, which was characterized. Three amino acid changes were found in the HA1 subunit of HA of MA virus. One of these was located inside the region of the conformational epitope recognized by MAb C179. However, this substitution was not significant for the recognition of HA and virus neutralization by MAb C179 in vitro and in vivo. Intraperitoneal administration of two different concentrations of MAb C179 one day before or two days after the virus challenge significantly decreased mortality rate. These results suggest that MAb C179 is efficient not only in the prevention and treatment of H1 and H2 influenza virus bronchopneumonia, as was reported previously, but also of H5-induced bronchopneumonia as well, and demonstrate in vivo the existence of a common neutralizing epitope in the HAs of these three subtypes.

Amino acid changes in the hemagglutinin and matrix proteins of influenza a (H2) viruses adapted to mice

Mouse-adapted (MA) variants of human and avian influenza A (H2) viruses were generated and characterized with respect to acquisition of virulence in mice. From the nucleotide sequence the amino acid sequence was deduced. The HA1 subunit of the hemagglutinin (HA) contained three amino acid substitutions in the A/black duck/New Jersey/1580/78-MA variant (Glu216-->Asp, Lys307-->Arg, and Thr318-->Ile) and two substitutions in the A/JapanxBellamy/57-MA variant (Lys25-->Thr and Ser203-->Phe). In the M1 protein, there were two substitutions in the A/black duck/New Jersey/1580/78-MA variant (Asn30-->Asp and Gln214-->His) and a single substitution in the A/JapanxBellamy/57-MA variant (Met179-->Lys). The M2 protein amino acid sequences of the parental virus and the MA variants differed by a single identical mutation (Asn93-->Ser). The localization and atomic distances of the observed mutations on the three-dimensional (3D) structure of the HA protein were analyzed for influenza H2 viruses. The obtained results were similar to those published earlier on H1, H3 and H5 subtypes. The amino acid changes in the HA protein could be divided into two groups. In one group the substitutions were situated at the top of the molecule, while in the other group they were clustered in the stem area at the interface region between three HA monomers. The analysis revealed that the substitutions observed in the MA variants probably increase the flexibility of the HA molecule and/or weaken the interactions between monomers or subunits in the HA trimer. The relationships of the observed amino acid changes in the HA and M proteins to the biological properties of the respective viruses and possible mechanisms involved in the acquisition of viral virulence are discussed.

G protein variation in respiratory syncytial virus group A does not correlate with clinical severity

Respiratory syncytial virus group A strain variations of 28 isolates from The Netherlands collected during three consecutive seasons were studied by analyzing G protein sequences. Several lineages circulated repeatedly and simultaneously during the respective seasons. No relationships were found between lineages on the one hand and clinical severity or age on the other.

Pandemic influenza is a zoonosis, as it requires introduction of avian-like gene segments in the human population

Human influenza viruses manage to cause epidemics almost every year. The circulating viruses change their surface glycoproteins by accumulating mutations (antigenic drift) which results in variant viruses of the same subtype that are able to evade the immune pressure in the population. Every now and then, a completely new subtype of influenza A virus is introduced in the human population, which can result in an influenza pandemic. Pandemic human influenza viruses have been emerging for many centuries. Based on the genetic information of influenza viruses that have been isolated in this century, introduction of genes of the avian influenza virus reservoir obviously is required. Interspecies transmission, via another mammalian host and reassortment of avian and human influenza viruses are potential mechanisms for such an introduction. A summary of the cases in which influenza viruses containing avian-like gene segments were introduced into the human population is presented. In three cases, such infections resulted in conjunctivitis. Influenza-like illness and even pneumonia was reported in some other infections. Finally, a mortality rate of 33% was observed in the avian influenza A (H5N1) viruses that infected 18 people in Hong Kong in 1997. Although some of these viruses fulfilled some criteria of pandemic influenza viruses, they lacked the ability to rapidly spread through the human population.

Characterization of adaptation of an avian influenza A (H5N2) virus to a mammalian host

We have used the mouse model to monitor the acquisition of virulence of a non-pathogenic influenza A virus upon adaptation to a new mammalian host. An avian strain, A/Mallard duck/Pennsylvania/10218/84 (H5N2) (Mld/PA/84) was adapted to mice by 23 serial lung-to-lung passages until a highly virulent mouse-adapted (MA) variant (Mld/PA/84-MA) emerged. This MA variant was characterized and compared to the parental strain as well as some of its intermediate passage variants. MA variant caused bronchopneumonia in mice with a high mortality rate (the virulence of Mld/PA/84-MA measured as log (EID50/LD50) was 1.75), while the parental, avirulent strain Mld/PA/84 did not cause illness and mortality in mice (log (EID50/LD50) was 7.25). Hemagglutination-inhibition (HAI) test with a set of hemagglutinin- (HA) specific monoclonal antibodies (MAbs) revealed antigenic differences between the parental strain and MA variant. Mld/PA/84-MA reacted with HA-specific MAbs in higher titers than the parental strain. The HA genes of the parental strain Mld/PA/84, the 1st, 3rd, 8th, and 15th intermediate passage variants, and Mld/PA/84-MA were sequenced. Three amino acid changes at positions 203, 273 and 320 were determined in the HA of MA variant. The first of them, Leu-->Pro (320), appeared in the HA stem region at the 8th passage. Two other in the HA1 globular region (Ser-->Phe (203) and Glu-->Gly (273)) appeared at the 15th passage. All of these substitutions were associated with the increase of viral infectivity for mouse lungs and changes in the HA antigenicity. The potential role of these changes in HA with respect to the process of viral interspecies transmission and acquisition of virulence for new host is discussed.

Zanamivir susceptibility monitoring and characterization of influenza virus clinical isolates obtained during phase II clinical efficacy studies

Zanamivir is a highly selective neuraminidase (NA) inhibitor with demonstrated clinical efficacy against influenza A and B virus infections. In phase II clinical efficacy trials (NAIB2005 and NAIB2008), virological substudies showed mean reductions in virus shedding after 24 h of treatment of 1.5 to 2.0 log(10) 50% tissue culture infective doses compared to a placebo, with no reemergence of virus after the completion of therapy. Paired isolates (n = 41) obtained before and during therapy with zanamivir demonstrated no shifts in susceptibility to zanamivir when measured by NA assays, although for a few isolates NA activity was too low to evaluate. In plaque reduction assays in MDCK cells, the susceptibility of isolates to zanamivir was extremely variable even at baseline and did not correlate with the speed of resolution of virus shedding. Isolates with apparent limited susceptibility to zanamivir by plaque reduction proved highly susceptible in vivo in the ferret model. Further sequence analysis of paired isolates revealed no changes in the hemagglutinin and NA genes in the majority of isolates. The few changes observed were all natural variants. No amino acid changes that had previously been identified in vitro as being involved with reduced susceptibility to zanamivir were observed. These studies highlighted problems associated with monitoring susceptibility to NA inhibitors in the clinic, in that no reliable cell-based assay is available. At present the NA assay is the best available predictor of susceptibility to NA inhibitors in vivo, as measured in the validated ferret model of infection.

Generation and characterization of reassortant influenza A viruses propagated in serum-free cultured MDCK-SF1 cells

The replacement of embryonated chicken eggs by tissue culture cells for the production of influenza vaccines is likely to take place in the near future. Vaccines have already been produced in Madin Darby Canine Kidney (MDCK) cells (Brands et al, in this issue) and extensively tested in phase III trials in humans (Palache et al, in this issue) and it seems a matter of time before such vaccines will become available. For this reason, the generation of high-growth reassortants of influenza A virus strains in MDCK cells has been examined. Influenza A virus reassortants of the field strains A/Taiwan/1/86, A/Johannesburg/82/96 and A/Shenzhen/227/95 (all H1N1) were generated in serum-free cultured MDCK-SF1 cells by dual infection with A/Hong Kong/2/68 (H3N2), a strain selected for its high-growth phenotype. These reassortant viruses all contained at least the matrix gene of A/Hong Kong/2/68 which apparently correlates with an improvement of the viral yield.

An epitope shared by the hemagglutinins of H1, H2, H5, and H6 subtypes of influenza A virus

The membrane-inserted hemagglutinin (HA) is the most variable protein of influenza viruses. Here we describe the characterization of a shared epitope in the HA of influenza A virus H1, H2, and H5 subtypes which were completely neutralized by a monoclonal antibody (MAb), directed against this epitope. This MAb (C179) also efficiently precipitated the HAs of these viruses. In addition, MAb C179 did not neutralize H6 subtype strains despite complete amino acid homology of the epitope regions. Furthermore, only the non-glycosylated form of the HA of one of the H6 subtype strains could be precipitated by the MAb. The conformational epitope may be masked by glycosylation, although it could not be excluded that differences in the primary amino acid sequence may cause the decreased accessibility of the epitope in H6 subtype strains.

Influenza virus subtype cross-reactivities of haemagglutination inhibiting and virus neutralising serum antibodies induced by infection or vaccination with an ISCOM-based vaccine

In order to study the levels of cross-reactivity of the influenza virus-specific antibody response upon infection or vaccination, usually hemagglutination inhibition assays are performed. In the present study post-infection ferret sera and serum samples obtained from cynomolgus macaques which were vaccinated with an ISCOM preparation based on the influenza virus strain A/Netherlands/18/94 (H3N2) were analyzed for cross-reactivity in the hemagglutination inhibition assay and in virus neutralization assays. It was shown that the cross-reactivity of the antibodies induced upon vaccination or infection with influenza virus proved to be more limited in the virus neutralization assay than in the hemagglutination assay. The strong antibody response induced by vaccination with the A/Netherlands/18/94-ISCOM preparation was shown to be cross-reactive with recent influenza virus strains, which were isolated since 1992, but not with older strains.

Characterization of high-growth reassortant influenza A viruses generated in MDCK cells cultured in serum-free medium

In the present study reassortant influenza A viruses of both the H1N1 and H3N2 type were generated in Madin Darby Canine Kidney cells grown in the absence of fetal bovine serum (MDCK-SF1 cells). To this end, MDCK-SF1 cells were simultaneously infected with one of the high-growth laboratory strains A/Puerto Rico/8/34 (H1N1) or A/Hong Kong/2/68 (H3N2) and recent H3N2 and H1N1 vaccine strains, respectively. Reassortant viruses obtained from these mixed infections were genetically characterized by RT-PCR and restriction enzyme analysis and their growth properties were compared to those of the corresponding field strains. Reassortant H3N2 viruses inherited the matrix and polymerase pa gene whilst H1N1 reassortant viruses inherited the matrix and polymerase pbl gene of the high-growth parent. Reassortant viruses generally gave higher viral yields, as measured by a haemagglutination assay, than their wild type counterparts. The procedure followed results in the generation of high-growth reassortant viruses in weeks. The use of MDCK-SF1 cells together with these reassortants for generating influenza virus antigens can significantly speed up the vaccine production procedure.

Rapid evolution of H5N1 influenza viruses in chickens in Hong Kong

The H5N1 avian influenza virus that killed 6 of 18 persons infected in Hong Kong in 1997 was transmitted directly from poultry to humans. Viral isolates from this outbreak may provide molecular clues to zoonotic transfer. Here we demonstrate that the H5N1 viruses circulating in poultry comprised two distinguishable phylogenetic lineages in all genes that were in very rapid evolution. When introduced into new hosts, influenza viruses usually undergo rapid alteration of their surface glycoproteins, especially in the hemagglutinin (HA). Surprisingly, these H5N1 isolates had a large proportion of amino acid changes in all gene products except in the HA. These viruses maybe reassortants each of whose HA gene is well adapted to domestic poultry while the rest of the genome arises from a different source. The consensus amino acid sequences of "internal" virion proteins reveal amino acids previously found in human strains. These human-specific amino acids may be important factors in zoonotic transmission.

ISCOM vaccine induced protection against a lethal challenge with a human H5N1 influenza virus

Recently avian influenza A viruses of the H5N1 subtype were shown to infect humans in the Hong Kong area, resulting in the death of six people. Although these viruses did not efficiently spread amongst humans, these events illustrated that influenza viruses of subtypes not previously detected in humans could be at the basis of a new pandemic. In the light of this pandemic threat we evaluated and compared the efficacy of a classical non-adjuvanted subunit vaccine and a vaccine based on immune stimulating complexes (ISCOM) prepared with the membrane glycoproteins of the human influenza virus A/Hong Kong 156/97 (H5N1) to protect roosters against a lethal challenge with this virus. The ISCOM vaccine induced protective immunity against the challenge infection whereas the non-adjuvanted subunit vaccine proved to be poorly immunogenic and failed to induce protection in this model.

Use of recombinant nucleoproteins in enzyme-linked immunosorbent assays for detection of virus-specific immunoglobulin A (IgA) and IgG antibodies in influenza virus A- or B-infected patients

The nucleoprotein genes of influenza virus A/Netherlands/018/94 (H3N2) and influenza virus B/Harbin/7/94 were cloned into the bacterial expression vector pMalC to yield highly purified recombinant influenza virus A and B nucleoproteins. With these recombinant influenza nucleoproteins, enzyme-linked immunosorbent assays (ELISAs) were developed for the detection of influenza virus A- and B-specific immunoglobulin A (IgA) and IgG serum antibodies. Serum samples were collected at consecutive time points after the onset of clinical symptoms from patients with confirmed influenza virus A or B infections. Nucleoprotein-specific IgA antibodies were detected in 41.2% of influenza virus A-infected patients and in 66. 7% of influenza virus B-infected patients on day 6 after the onset of clinical symptoms. In serum samples taken on day 21 (influenza virus A-infected patients) or day 28 (influenza virus B-infected patients), nucleoprotein-specific IgA antibodies could be detected in 58.8 and 58.3% of influenza virus A- and B-infected patients, respectively. At the same time, IgG antibody rises were detected in 88.2% of influenza virus A-infected patients and in 95.8% of influenza virus B-infected patients. On comparison, hemagglutination inhibition assays detected antibody titer rises in 81.3 and 72.7% of patients infected with influenza viruses A and B, respectively. In contrast to the detection of nucleoprotein-specific IgG antibodies or hemagglutination-inhibiting antibodies, the detection of nucleoprotein-specific IgA antibodies does not require paired serum samples and therefore can be considered an attractive alternative for the rapid serological diagnosis of influenza.

[The influenza season 1997/'98 and the vaccine composition for 1998/'99]

The 1997/'98 influenza season in the Netherlands was marked by influenza A/H3N2 activity which never reached a true epidemic level. There was no real peak activity either but a prolonged period of increased activity of approximately eight weeks with a maximum in week 13, when sentinel physicians reported 16.6 cases of influenza-like illness per 10,000 inhabitants. It was not until week 18 of 1998 that the influenza activity declined to baseline levels. During the season, almost exclusively influenza A/H3N2 viruses were isolated, of which the majority resembled the new strain influenza A/Sydney/5/97 (H3N2). Further analysis of these variant viruses revealed that, although there was some cross-reactivity with the vaccine strain (A/Nanchang/933/95), no optimal protection could be expected to be induced by the vaccine. Antigenic characterisation of the sporadic influenza A/H1N1 and influenza B viruses showed that these were related to the vaccine strains. As a result of these findings, the World Health Organization (WHO) recommended to change the H3N2 strain in the influenza vaccine for the season 1998/'99 to an influenza A/Sydney/5/97(H3N2)-like strain. Based on epidemiological data from other countries, it was also decided to change the influenza A/H1N1 component to an influenza A/Beijing/262/95 (H1N1)-like strain.

Comparison of RNA hybridization, hemagglutination assay, titration of infectious virus and immunofluorescence as methods for monitoring influenza virus replication in vitro

Rapid and sensitive methods for the monitoring of influenza virus replication in vitro are needed to address several research questions. Four methods based on different principles were compared: the hemagglutination (HA) assay, the measurement of virus infectivity titers in culture supernatants, the enumeration of infected cells by immunofluorescence and RNA hybridization techniques using digoxigenin (DIG) labeled RNA probes. To this end, MDCK cells were infected at different multiplicities of infection (moi) with a recent influenza A virus (A/Netherlands/18/94 H3N2) and the kinetics of virus replication were monitored with these four assays. At high moi, virus released into the culture supernatant of infected cells was detected by the HA assay 12 h post infection, whereas at lower moi (< or = 0.01) the first HA activity was not detected before 24 h post infection. The measurement of infectious viruses in the culture supernatant proved to be more sensitive, since 4-12 h post infection newly produced virus was detected depending on the moi used. This finding was in agreement with results obtained by the immunofluorescence assay using an antibody preparation specific for the nucleoprotein: single infected cells could be detected as early as 4 h post infection. At this time point, positive signals were also obtained when mRNA/cRNA specific hybridization was carried out for the NP gene segment, but not for viral NP RNA or RNA specific for the hemagglutinin, which were only detected at later time points after infection. Thus, besides direct measurement of infectious virus and immunofluorescence, RNA hybridization proved to be a sensitive assay for monitoring influenza virus replication in vitro.

[Influenza A (H5N1) in Hong Kong: Forerunner of a pandemic or just a scientifically interesting phenomenon and a useful exercise in pandemiology?]

In 1997, 18 influenza patients were detected who were infected with influenza A(H5N1) virus. Six patients died. Presumably most of the patients had acquired the infection directly from chickens with the fowl plague prevalent in China in 1997. These are the first reported cases of isolation of influenza viruses belonging to one of the H4-H15 subtypes from human influenza patients. Man-to-man transmission of the virus has not been demonstrated but cannot be excluded in every case. Genetic analyses of seven of these virus isolates showed that no reassortment with a human or porcine influenza virus had occurred. It is unpredictable whether the H5N1-virus in question will start a pandemic in the next few years.

[Influenza A(H5N1) in Hong Kong: forerunner of a pandemic or an only scientifically interesting phenomenon and a useful exercise in pandemiology?]

From a three-year old boy in Hong Kong who died in May 1997 with an extensive influenza pneumonia an influenza A virus has been isolated which was, first at the National Influenza Centre of the Netherlands, identified as belonging to subtype H5N1. Presumably the patient had acquired the infection directly from an outbreak of fowl plague among chickens. As far as is known this is the first case of the isolation of an influenza virus belonging to one of the subtypes H4-H15 from a human influenza patient. At the end of 1997 seventeen more cases of human A (H5N1) influenza have been detected in Hong Kong, including five fatal cases. Genetic analyses of seven of these virus isolates did not reveal the occurrence of reassortment with a human or porcine influenza virus, which could have rendered the virus potentially pandemic. Man-to-man transmission of the virus has not been demonstrated but cannot be excluded either. This event has shown that the WHO surveillance of influenza viruses, although perhaps not perfect, has functioned well.

Human influenza virus A/HongKong/156/97 (H5N1) infection

Introduction of influenza viruses with gene segments of avian origin into the human population may result in the emergence of new pathogenic human influenza viruses. The recent infection of a 3-year-old boy with an influenza A (H5N1) virus of avian origin can be considered as an example of such an event. However, this virus, influenza A/Hong Kong/156/97 (H5N1) and the 17 additional H5N1 viruses isolated from humans by the end of 1997 lack the ability to spread efficiently amongst humans and therefore have limited pandemic potential. However, the possibility of reassortment of these viruses with currently circulating human viruses illustrates the need for pandemic preparedness.

Human influenza A H5N1 virus related to a highly pathogenic avian influenza virus

BACKGROUND

In May, 1997, a 3-year-old boy in Hong Kong was admitted to the hospital and subsequently died from influenza pneumonia, acute respiratory distress syndrome, Reye's syndrome, multiorgan failure, and disseminated intravascular coagulation. An influenza A H5N1 virus was isolated from a tracheal aspirate of the boy. Preceding this incident, avian influenza outbreaks of high mortality were reported from three chicken farms in Hong Kong, and the virus involved was also found to be of the H5 subtype.

METHODS

We carried out an antigenic and molecular comparison of the influenza A H5N1 virus isolated from the boy with one of the viruses isolated from outbreaks of avian influenza by haemagglutination-inhibition and neuraminidase-inhibition assays and nucleotide sequence analysis.

FINDINGS

Differences were observed in the antigenic reactivities of the viruses by the haemagglutination-inhibition assay. However, nucleotide sequence analysis of all gene segments revealed that the human virus A/Hong Kong/156/97 was genetically closely related to the avian A/chicken/Hong Kong/258/97.

INTERPRETATION

Although direct contact between the sick child and affected chickens has not been established, our results suggest transmission of the virus from infected chickens to the child without another intermediate mammalian host acting as a "mixing vessel". This event illustrates the importance of intensive global influenza surveillance.

[Influenza in the 1996/'97 season; vaccine composition for the 1997/'98 season]

The first indication of flu activity in the Netherlands in the 1996/'97 season was the isolation of an A/H3N2 influenza virus in week 48 of 1996. In subsequent weeks influenza viruses were isolated sporadically. The clinical influenza activity increased from week I of 1997 and reached its peak in week 4 of 1997. Simultaneously with the increase of clinical influenza activity, an increasing number of influenza viruses were isolated. The epidemic had a relatively small extent. Initially, A/H3N2 influenza viruses were predominant, but in the second half of the epidemic an increasing number of influenza B viruses were isolated as well. The A/H3N2 viruses were antigenically fairly strongly distinct from the variants prevalent in the preceding years. This season influenza A/HINI viruses did not play a significant role and only one virus of this subtype was isolated. All influenza A/H3N2, A/HINI and B viruses isolated were antigenically similar to the vaccine strains.

Respiratory syncytial virus specific serum antibodies in infants under six months of age: limited serological response upon infection

The decline of maternal respiratory syncytial virus (RSV) specific serum antibodies was studied in 45 children during the first 6 months of life, using a virus neutralization assay and competition ELISAs measuring fusion protein and glycoprotein specific antibodies. In all children RSV neutralizing antibodies were demonstrated at birth, with titers ranging from 33 to 1382. The calculated mean half life of these antibodies was 26 days. Furthermore, in a group of 38 children with suspected RSV infection, all younger than 6 months of age on admission, the diagnostic value of serological assays was evaluated. In 32 children RSV infection was confirmed by virus isolation, direct immune fluorescence and RT-PCR. In 7 patients of this group a significant titer rise in virus neutralization assay was demonstrated. Six additional RSV infected children could be identified by showing the presence of RSV-specific IgM or IgA serum antibodies or by showing an increase in fusion protein or glycoprotein specific antibodies. All serological tests together identified 13 (41%) of the 32 RSV infected patients. It is concluded that in children of this age group, which represent the majority of patients hospitalized with RSV infections, serological assays not only have a limited diagnostic value but are of limited value for sero-epidemiological studies.

Induction of protective immunity against influenza virus in a macaque model: comparison of conventional and iscom vaccines

Cynomolgus macaque monkeys (Macaca fascicularis) were immunized twice intramuscularly, either with a conventional non-adjuvanted subunit vaccine or with a candidate immune-stimulating complex (iscom) vaccine, each containing 10 micrograms envelope glycoprotein of a recent human influenza A(H3N2) virus (A/Netherlands/18/94). In contrast to the macaques vaccinated with the classical subunit vaccine, those immunized with the iscom vaccine developed high titres of specific IgM, IgA and IgG serum antibodies, as well as high titres of haemagglutination-inhibiting and virus-neutralizing serum antibodies. Also, specific proliferative T cell responses were only found in the iscom-vaccinated monkeys and their levels were similar to those found in monkeys experimentally infected with the homologous virus. Upon intratracheal challenge with the homologous virus, the iscom-vaccinated monkeys were completely protected from detectable virus replication in lungs, pharynx and nose, whereas those vaccinated with the classical subunit vaccines were not, or were only partially protected. The kinetics of specific serum antibody development in the iscom-vaccinated monkeys after challenge were quite similar to those of monkeys after secondary infection with the same virus. In contrast, the post-challenge kinetics of serum antibody development in the monkeys vaccinated with the classical subunit vaccines resembled those of naive monkeys, confirming that these vaccines only provided limited protection in such animals.

A pandemic warning?

Introduction of new influenza type-A viruses, carrying different combinations of the viral envelope glycoproteins haemagglutinin (H) and neuraminidase (N), have led to three major pandemics of influenza in humans this century. Phylogenetic evidence suggests that these viruses have originated from avian influenza A viruses, either unchanged or after reassortment with humaninfluenza A viruses. In aquatic birds, all of the known H and N antigenic varieties (15 varieties carry H, nine carry N envelope glycoproteins) apparently circulate in a genetically conserved fashion. Viruses carrying the H1N1, H2N2 and H3N2 combinations were responsible for the Spanish flu of 1918, the Asian flu in 1957 and Hong Kong flu in 1968, respectively¹. An influenza A virus of the H5N1 subtype has now been identified in a human patient, raising discussions about its potential to spark a new human influenza pandemic.

[Influenza in the 1995/'96 season; vaccine composition for the 1996/'97 season]

The 1995/'96 season in the Netherlands was marked by an influenza A/H3N2 epidemic that peaked in week 5I. In this week, 39 patients with influenza-like illness per 10,000 inhabitants contacted the sentinel physicians. With two exceptions, influenza A/H3N2 viruses exclusively were isolated during this epidemic period. In the first few months of 1996, a substantial number of influenza A/H1N1 and influenza B viruses were isolated as well. Serological characterization of the circulating viruses revealed that they all resembled the virus strains of the influenza vaccine of 1995/'96, which therefore probably will have provided good protection. Based on the epidemiological data from other countries and the fact that similar H3N2 viruses have been circulating since 1993, the World Health Organization has recommended to exchange the H3N2 component of the 1996/'97 vaccine for a Wuhan/353/95 (H3N2)-like strain.

Genetic reassortment in pandemic and interpandemic influenza viruses. A study of 122 viruses infecting humans

The human influenza pandemics of 1957 and 1968 were caused by reassortant viruses that possessed internal gene segments from avian and human strains. Whether genetic reassortment of human and avian influenza viruses occurs during interpandemic periods and how often humans are infected with such reassortants is not known. To provide this information, we used dot-blot hybridization, partial nucleotide sequencing and subsequent phylogenetic analysis to examine the 6 internal genes of 122 viruses isolated in humans between 1933 and 1992 primarily from Asia, Europe, and the Americas. The internal genes of A/New Jersey/11/76 isolated from a human fatality at Fort Dix, New Jersey in 1976 were found to be of porcine origin. Although none of the geographically and temporally diverse collection of 122 viruses was an avian-human or other reassortant, cognizance was made of the fact that there were two isolates from children from amongst 546 influenza A isolates obtained from The Netherlands from 1989-1994 which were influenza A reassortants containing genes of avian origin, viruses which have infected European pigs since 1983-1985. Thus, genetic reassortment between avian and human influenza strains does occur in the emergence of pandemic and interpandemic influenza A viruses. However, in the interpandemic periods the reassortants have no survival advantage, and the circulating interpandemic influenza viruses in humans do not appear to accumulate avian influenza virus genes.

[Influenza in the 1994/95 season; composition of vaccine for the 1995/96 season]

The 1994/'95 season in the Netherlands was marked by a limited influenza activity which only emerged in late February. The influenza activity remained elevated until the end of April, which is unusually late, and epidemic activity was only reported in the south of the country. Both influenza A/H3N2 and B viruses were isolated in this period. In addition, influenza A/HINI viruses were isolated for the first time since March 1993, from two patients. The majority of the influenza A strains that circulated in the Netherlands in 1994/'95 reacted well with ferret antiserum raised against the strains of the 1994/'95 influenza vaccine, which therefore probably offered good protection. The reactivity of the B strains to antiserum raised against the vaccine strain, B/Panama/45/90, was only moderate, which implies that the protection against the Dutch influenza B strains was not optimal. Based on the results of the worldwide influenza surveillance, the World Health Organization (WHO) has recommended an alteration in both the A/H3N2 and the B component for the vaccine of 1995/1996.

Interspecies transmission of influenza viruses

In this report we examine the hypothesis that aquatic birds are the primordial source of all influenza viruses in other species. Two partly overlapping reservoirs of influenza A viruses exist in migrating water-fowl and shorebirds throughout the world. These species harbor influenza viruses of all the known hemagglutinin and neuraminidase subtypes. In contrast to the rapid, progressive changes in both the nucleotide and amino acid sequences of mammalian virus gene lineages, avian virus genes show far less variation and, in most cases, appear to be in evolutionary stasis. There are periodic exchanges of influenza virus genes or whole viruses between species, giving rise to pandemics of disease in humans, lower animals, and birds. The periodic exchange of influenza viruses between species has been illustrated by the appearance of new pandemic influenza viruses in humans, including the Spanish influenza of 1918, the Asian influenza of 1957, and the Hong Kong influenza of 1968. Transmission of avian influenza viruses to swine in Europe in 1979 has resulted in the appearance of human-avian reassortant influenza viruses in pigs in Italy and in children in the Netherlands. These studies provide evidence supporting the possibility that pigs serve as a mixing vessel for reassortment between influenza viruses in mammalian and avian hosts and raise the question of whether the avian influenza viruses now circulating in European swine are the precursors of the next human pandemic virus.

Infection of children with avian-human reassortant influenza virus from pigs in Europe

Pigs have been proposed to act as the intermediate hosts in the generation of pandemic human influenza strains by reassortment of genes from avian and human influenza virus strains. The circulation of avian-like H1N1 influenza viruses in European pigs since 1979 and the detection of human-avian reassortants in pigs raises the question of whether these viruses actually have the potential to transmit and cause disease in humans. We now report the serologic and genetic characterization of two human influenza A viruses (A/Netherlands/5/93 [H3N2] and A/Netherlands/35/93 [H3N2]) that caused influenza in children in The Netherlands in 1993. The results show that these viruses are human-avian ressortants that were generated and currently still are circulating in European swine. This shows the pivotal role that pigs can play in the generation and transmission of avian influenza virus genes to humans and their potential to generate a new human pandemic strain.

[Influenza in the 1993/'94 season; composition of the vaccine for the 1994/'95 season]

The influenza season 1993/'94 in the Netherlands and the rest of Northwestern Europe was marked by an influenza A/H3N2 epidemic. The morbidity of this epidemic was moderate, but a high mortality rate was observed. The epidemic viruses, represented by A/Netherlands/241/93 (H3N2), were characterised by haemagglutination inhibition assays and nucleotide sequence analysis. The viruses were related to A/Beijing/32/92 (H3N2), the vaccine strain for 1993/'94, but clear antigenic differences were detected. Therefore, the WHO has recommended a new A/H3N2 component, A/Shangdong/9/93, for the vaccine of 1994/'95. The onset of the epidemic was unusually early in the influenza season. An increase in the influenza activity was already noticed in the second week of November and it reached its peak in week 49. As a result of the early epidemic, the influenza vaccination programme had not been completed yet. Therefore, the point of time for vaccinating people at risk may have to be reconsidered and moved up in order to complete the vaccination programme earlier.

Detection of respiratory syncytial virus by RNA-polymerase chain reaction and differentiation of subgroups with oligonucleotide probes

The polymerase chain reaction (RNA-PCR) was used for specific detection of respiratory syncytial virus (RSV) genomes in clinical specimens. A set of primers was selected from conserved regions of the 1B and N genes for detection of both subgroups. The primers were found to be RSV specific, all RSV strains generated a 218 bp product, and no RSV specific amplified product was obtained when nucleic acids from a variety of micro-organisms from the respiratory tract were subjected to the RNA-PCR. We took advantage of the sequence heterogeneity of the amplified products to discriminate between the A and B strains by hybridisation with subgroup specific oligonucleotide probes. This additional hybridisation assay increased the sensitivity of the RNA-PCR tenfold. The RNA-PCR was tested on clinical specimens from children with symptoms of an infection of the respiratory tract. The results were compared with isolation of RSV in cell culture and direct immunofluorescence. From 93 specimens tested, 31 were found positive by all three techniques. Six additional positive results were detected using RNA-PCR. From these 37 RSV positive specimens 33 (92%), including all 6 additional positives, were subgroup A and only 4 were subgroup B strains. Thus, the RNA-PCR is a specific and sensitive technique for the detection and subgroup classification of RSV genomes.

Detection of infections of the eye with Chlamydia trachomatis by the polymerase chain reaction

The aim of this study was to test the diagnostic feasibility of the polymerase chain reaction (PCR) for detection of infections with Chlamydia trachomatis in eye swabs from patients with conjunctivitis, and to establish the basic technique of the PCR for epidemiological survey. The results of the PCR were compared with the Mikro Trak immunofluorescence assay (IFA). From 49 specimens of patients with conjunctivitis, 31 were found positive by PCR (63%) and 23 by IFA (47%). On the other hand, in 10 normal eye specimens and 10 non-Chlamydia trachoma conjunctivitis specimens no Chlamydia trachomatis was detected.

Prospective application of reverse transcriptase polymerase chain reaction for diagnosing influenza infections in respiratory samples from a children's hospital

A prospective clinical evaluation of the reverse transcriptase polymerase chain reaction (RNA PCR) for detection of influenza viruses was carried out with specimens from 342 patients of a children's hospital in The Netherlands. The RNA PCR, carried out directly on the specimens without an organic extraction, showed a sensitivity and specificity which are superior to those of direct immunofluorescence and comparable to those of cell culture combined with immunofluorescence (culture/IF). Negative results can be obtained within 2 days by the RNA PCR but may take up to 14 days by culture/IF. Because culturing is the standard technique for the detection of respiratory viruses, at this moment there are no strong arguments to replace culture/IF with RNA PCR for the detection of influenza A virus.

Type-specific identification of influenza viruses A, B and C by the polymerase chain reaction

The aim of this study was to develop a polymerase chain reaction for specific detection of influenza A, B, and C RNA genomes. Three primer sets were selected from conserved regions of the genome coding for the non-structural proteins and were tested on 61 influenza A (22 H1N1, 9 H2N2, and 30 H3N2), 11 influenza B, and three influenza C isolates. Specific amplified products were obtained with all these strains after electrophoresis on a 2% agarose gel. The specificity of the reaction was increased by hybridization with oligonucleotide probes. When nucleic acids from a variety of micro-organisms from the respiratory tract were subjected to the PCR with these primers, no specific amplified products were generated. The sensitivity of the technique was found to be at the subpicogram level. The RNA-PCR was applied to 21 clinical specimens from patients with a culture/IF proven influenza infection. Six influenza A positive patients and 13 influenza B positive patients could be confirmed in the RNA-PCR. In two cases, influenza B positive IF specimens were found negative by the PCR. No virus could be isolated on eggs or tissue culture from these samples. RNA-PCR is a specific and sensitive technique for the detection of influenza virus genomes.

Infections of the cervix uteri with human papillomavirus and Chlamydia trachomatis

Apart from infection with human papillomavirus (HPV), other microorganisms may be involved in the development of cervical neoplasia. To study concomitant infections with HPV and Chlamydia trachomatis, cervical specimens from 4 groups of women were examined for the presence of these microorganisms by the polymerase chain reaction. The first group consisted of 143 consecutive samples from women with no cytological abnormalities who participated in a triennial screening program to prevent cervical cancer. In this group 2 samples were found positive for HPV and 2 additional samples were found positive for C. trachomatis. In the second group of 46 cytologically abnormal smears, HPV DNA was detected in 71.7% of the samples and C. tra chomatis in 4.3%. In a third group of 94 histological abnormal biopsies, the HPV prevalence ranged from 15% in mild dysplastic lesions up to 92% in invasive cervical carcinomas. Only 2 biopsies of this group (2.1%) were found positive for C. trachomatis. Finally, a group of cervical scrapes was obtained from women attending a clinic for sexually transmitted diseases. In 52 samples positive for C. trachomatis and 60 samples negative for C. trachomatis, no significant (P = 0.57) difference in the frequency of HPV infections was found (11.5% and 8.3%, respectively). The data show that in these study groups HPV and C. trachomatis are independently occurring agents.