Association of Chronic Medical Conditions With Severe Outcomes Among Nonpregnant Adults 18-49 Years Old Hospitalized With Influenza, FluSurv-NET, 2011-2019

Background

Older age and chronic conditions are associated with severe influenza outcomes; however, data are only comprehensively available for adults ≥65 years old. Using data from the Influenza Hospitalization Surveillance Network (FluSurv-NET), we identified characteristics associated with severe outcomes in adults 18-49 years old hospitalized with influenza.

Methods

We included FluSurv-NET data from nonpregnant adults 18-49 years old hospitalized with laboratory-confirmed influenza during the 2011-2012 through 2018-2019 seasons. We used bivariate and multivariable logistic regression to determine associations between select characteristics and severe outcomes including intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), and in-hospital death.

Results

A total of 16 140 patients aged 18-49 years and hospitalized with influenza were included in the analysis; the median age was 39 years, and 26% received current-season influenza vaccine before hospitalization. Obesity, asthma, and diabetes mellitus were the most common chronic conditions. Conditions associated with a significantly increased risk of severe outcomes included age group 30-39 or 40-49 years (IMV, age group 30-39 years: adjusted odds ratio [aOR], 1.25; IMV, age group 40-49 years: aOR, 1.36; death, age group 30-39 years: aOR, 1.28; death, age group 40-49 years: aOR, 1.69), being unvaccinated (ICU: aOR, 1.18; IMV: aOR, 1.25; death: aOR, 1.48), and having chronic conditions including extreme obesity and chronic lung, cardiovascular, metabolic, neurologic, or liver diseases (ICU: range aOR, 1.22-1.56; IMV: range aOR, 1.17-1.54; death: range aOR, 1.43-2.36).

Conclusions

To reduce the morbidity and mortality associated with influenza among adults aged 18-49 years, health care providers should strongly encourage receipt of annual influenza vaccine and lifestyle/behavioral modifications, particularly among those with chronic medical conditions.

Characteristics and Outcomes Among Adults Aged ≥60 Years Hospitalized with Laboratory-Confirmed Respiratory Syncytial Virus - RSV-NET, 12 States, July 2022-June 2023

Respiratory syncytial virus (RSV) causes substantial morbidity and mortality in older adults. In May 2023, two RSV vaccines were approved for prevention of RSV lower respiratory tract disease in adults aged ≥60 years. In June 2023, CDC recommended RSV vaccination for adults aged ≥60 years, using shared clinical decision-making. Using data from the Respiratory Syncytial Virus-Associated Hospitalization Surveillance Network, a population-based hospitalization surveillance system operating in 12 states, this analysis examined characteristics (including age, underlying medical conditions, and clinical outcomes) of 3,218 adults aged ≥60 years who were hospitalized with laboratory-confirmed RSV infection during July 2022-June 2023. Among a random sample of 1,634 older adult patients with RSV-associated hospitalization, 54.1% were aged ≥75 years, and the most common underlying medical conditions were obesity, chronic obstructive pulmonary disease, congestive heart failure, and diabetes. Severe outcomes occurred in 18.5% (95% CI = 15.9%-21.2%) of hospitalized patients aged ≥60 years. Overall, 17.0% (95% CI = 14.5%-19.7%) of patients with RSV infection were admitted to an intensive care unit, 4.8% (95% CI = 3.5%-6.3%) required mechanical ventilation, and 4.7% (95% CI = 3.6%-6.1%) died; 17.2% (95% CI = 14.9%-19.8%) of all cases occurred in long-term care facility residents. These data highlight the importance of prioritizing those at highest risk for severe RSV disease and suggest that clinicians and patients consider age (particularly age ≥75 years), long-term care facility residence, and underlying medical conditions, including chronic obstructive pulmonary disease and congestive heart failure, in shared clinical decision-making when offering RSV vaccine to adults aged ≥60 years.

High Influenza Incidence and Disease Severity Among Children and Adolescents Aged <18 Years - United States, 2022-23 Season

During the 2022-23 influenza season, early increases in influenza activity, co-circulation of influenza with other respiratory viruses, and high influenza-associated hospitalization rates, particularly among children and adolescents, were observed. This report describes the 2022-23 influenza season among children and adolescents aged <18 years, including the seasonal severity assessment; estimates of U.S. influenza-associated medical visits, hospitalizations, and deaths; and characteristics of influenza-associated hospitalizations. The 2022-23 influenza season had high severity among children and adolescents compared with thresholds based on previous seasons' influenza-associated outpatient visits, hospitalization rates, and deaths. Nationally, the incidences of influenza-associated outpatient visits and hospitalization for the 2022-23 season were similar for children aged <5 years and higher for children and adolescents aged 5-17 years compared with previous seasons. Peak influenza-associated outpatient and hospitalization activity occurred in late November and early December. Among children and adolescents hospitalized with influenza during the 2022-23 season in hospitals participating in the Influenza Hospitalization Surveillance Network, a lower proportion were vaccinated (18.3%) compared with previous seasons (35.8%-41.8%). Early influenza circulation, before many children and adolescents had been vaccinated, might have contributed to the high hospitalization rates during the 2022-23 season. Among symptomatic hospitalized patients, receipt of influenza antiviral treatment (64.9%) was lower than during pre-COVID-19 pandemic seasons (80.8%-87.1%). CDC recommends that all persons aged ≥6 months without contraindications should receive the annual influenza vaccine, ideally by the end of October.

Characteristics and Outcomes Among Adults Aged ≥60 Years Hospitalized with Laboratory-Confirmed Respiratory Syncytial Virus - RSV-NET, 12 States, July 2022-June 2023

Respiratory syncytial virus (RSV) causes substantial morbidity and mortality in older adults. In May 2023, two RSV vaccines were approved for prevention of RSV lower respiratory tract disease in adults aged ≥60 years. In June 2023, CDC recommended RSV vaccination for adults aged ≥60 years, using shared clinical decision-making. Using data from the Respiratory Syncytial Virus-Associated Hospitalization Surveillance Network, a population-based hospitalization surveillance system operating in 12 states, this analysis examined characteristics (including age, underlying medical conditions, and clinical outcomes) of 3,218 adults aged ≥60 years who were hospitalized with laboratory-confirmed RSV infection during July 2022-June 2023. Among a random sample of 1,634 older adult patients with RSV-associated hospitalization, 54.1% were aged ≥75 years, and the most common underlying medical conditions were obesity, chronic obstructive pulmonary disease, congestive heart failure, and diabetes. Severe outcomes occurred in 18.5% (95% CI = 15.9%-21.2%) of hospitalized patients aged ≥60 years. Overall, 17.0% (95% CI = 14.5%-19.7%) of patients with RSV infection were admitted to an intensive care unit, 4.8% (95% CI = 3.5%-6.3%) required mechanical ventilation, and 4.7% (95% CI = 3.6%-6.1%) died; 17.2% (95% CI = 14.9%-19.8%) of all cases occurred in long-term care facility residents. These data highlight the importance of prioritizing those at highest risk for severe RSV disease and suggest that clinicians and patients consider age (particularly age ≥75 years), long-term care facility residence, and underlying medical conditions, including chronic obstructive pulmonary disease and congestive heart failure, in shared clinical decision-making when offering RSV vaccine to adults aged ≥60 years.

COVID-19-Associated Hospitalizations Among U.S. Adults Aged ≥65 Years - COVID-NET, 13 States, January-August 2023

Adults aged ≥65 years remain at elevated risk for severe COVID-19 disease and have higher COVID-19-associated hospitalization rates compared with those in younger age groups. Data from the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) were analyzed to estimate COVID-19-associated hospitalization rates during January-August 2023 and identify demographic and clinical characteristics of hospitalized patients aged ≥65 years during January-June 2023. Among adults aged ≥65 years, hospitalization rates more than doubled, from 6.8 per 100,000 during the week ending July 15 to 16.4 per 100,000 during the week ending August 26, 2023. Across all age groups, adults aged ≥65 years accounted for 62.9% (95% CI = 60.1%-65.7%) of COVID-19-associated hospitalizations, 61.3% (95% CI = 54.7%-67.6%) of intensive care unit admissions, and 87.9% (95% CI = 80.5%-93.2%) of in-hospital deaths associated with COVID-19 hospitalizations. Most hospitalized adults aged ≥65 years (90.3%; 95% CI = 87.2%-92.8%) had multiple underlying conditions, and fewer than one quarter (23.5%; 95% CI = 19.5%-27.7%) had received the recommended COVID-19 bivalent vaccine. Because adults aged ≥65 years remain at increased risk for COVID-19-associated hospitalization and severe outcomes, guidance for this age group should continue to focus on measures to prevent SARS-CoV-2 infection, encourage vaccination, and promote early treatment for persons who receive a positive SARS-CoV-2 test result to reduce their risk for severe COVID-19-associated outcomes.

Clinical Trends Among U.S. Adults Hospitalized With COVID-19, March to December 2020 : A Cross-Sectional Study

BACKGROUND

The COVID-19 pandemic has caused substantial morbidity and mortality.

OBJECTIVE

To describe monthly clinical trends among adults hospitalized with COVID-19.

DESIGN

Pooled cross-sectional study.

SETTING

99 counties in 14 states participating in the Coronavirus Disease 2019-Associated Hospitalization Surveillance Network (COVID-NET).

PATIENTS

U.S. adults (aged ≥18 years) hospitalized with laboratory-confirmed COVID-19 during 1 March to 31 December 2020.

MEASUREMENTS

Monthly hospitalizations, intensive care unit (ICU) admissions, and in-hospital death rates per 100 000 persons in the population; monthly trends in weighted percentages of interventions, including ICU admission, mechanical ventilation, and vasopressor use, among an age- and site-stratified random sample of hospitalized case patients.

RESULTS

Among 116 743 hospitalized adults with COVID-19, the median age was 62 years, 50.7% were male, and 40.8% were non-Hispanic White. Monthly rates of hospitalization (105.3 per 100 000 persons), ICU admission (20.2 per 100 000 persons), and death (11.7 per 100 000 persons) peaked during December 2020. Rates of all 3 outcomes were highest among adults aged 65 years or older, males, and Hispanic or non-Hispanic Black persons. Among 18 508 sampled hospitalized adults, use of remdesivir and systemic corticosteroids increased from 1.7% and 18.9%, respectively, in March to 53.8% and 74.2%, respectively, in December. Frequency of ICU admission, mechanical ventilation, and vasopressor use decreased from March (37.8%, 27.8%, and 22.7%, respectively) to December (20.5%, 12.3%, and 12.8%, respectively); use of noninvasive respiratory support increased from March to December.

LIMITATION

COVID-NET covers approximately 10% of the U.S. population; findings may not be generalizable to the entire country.

CONCLUSION

Rates of COVID-19-associated hospitalization, ICU admission, and death were highest in December 2020, corresponding with the third peak of the U.S. pandemic. The frequency of intensive interventions for management of hospitalized patients decreased over time. These data provide a longitudinal assessment of clinical trends among adults hospitalized with COVID-19 before widespread implementation of COVID-19 vaccines.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Census tract socioeconomic indicators and COVID-19-associated hospitalization rates-COVID-NET surveillance areas in 14 states, March 1-April 30, 2020

OBJECTIVES

Some studies suggested more COVID-19-associated hospitalizations among racial and ethnic minorities. To inform public health practice, the COVID-19-associated Hospitalization Surveillance Network (COVID-NET) quantified associations between race/ethnicity, census tract socioeconomic indicators, and COVID-19-associated hospitalization rates.

METHODS

Using data from COVID-NET population-based surveillance reported during March 1-April 30, 2020 along with socioeconomic and denominator data from the US Census Bureau, we calculated COVID-19-associated hospitalization rates by racial/ethnic and census tract-level socioeconomic strata.

RESULTS

Among 16,000 COVID-19-associated hospitalizations, 34.8% occurred among non-Hispanic White (White) persons, 36.3% among non-Hispanic Black (Black) persons, and 18.2% among Hispanic or Latino (Hispanic) persons. Age-adjusted COVID-19-associated hospitalization rate were 151.6 (95% Confidence Interval (CI): 147.1-156.1) in census tracts with >15.2%-83.2% of persons living below the federal poverty level (high-poverty census tracts) and 75.5 (95% CI: 72.9-78.1) in census tracts with 0%-4.9% of persons living below the federal poverty level (low-poverty census tracts). Among White, Black, and Hispanic persons living in high-poverty census tracts, age-adjusted hospitalization rates were 120.3 (95% CI: 112.3-128.2), 252.2 (95% CI: 241.4-263.0), and 341.1 (95% CI: 317.3-365.0), respectively, compared with 58.2 (95% CI: 55.4-61.1), 304.0 (95%: 282.4-325.6), and 540.3 (95% CI: 477.0-603.6), respectively, in low-poverty census tracts.

CONCLUSIONS

Overall, COVID-19-associated hospitalization rates were highest in high-poverty census tracts, but rates among Black and Hispanic persons were high regardless of poverty level. Public health practitioners must ensure mitigation measures and vaccination campaigns address needs of racial/ethnic minority groups and people living in high-poverty census tracts.

Effectiveness of COVID-19 Vaccines in Preventing Hospitalization Among Adults Aged ≥65 Years - COVID-NET, 13 States, February-April 2021

Clinical trials of COVID-19 vaccines currently authorized for emergency use in the United States (Pfizer-BioNTech, Moderna, and Janssen [Johnson & Johnson]) indicate that these vaccines have high efficacy against symptomatic disease, including moderate to severe illness (1-3). In addition to clinical trials, real-world assessments of COVID-19 vaccine effectiveness are critical in guiding vaccine policy and building vaccine confidence, particularly among populations at higher risk for more severe illness from COVID-19, including older adults. To determine the real-world effectiveness of the three currently authorized COVID-19 vaccines among persons aged ≥65 years during February 1-April 30, 2021, data on 7,280 patients from the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) were analyzed with vaccination coverage data from state immunization information systems (IISs) for the COVID-NET catchment area (approximately 4.8 million persons). Among adults aged 65-74 years, effectiveness of full vaccination in preventing COVID-19-associated hospitalization was 96% (95% confidence interval [CI] = 94%-98%) for Pfizer-BioNTech, 96% (95% CI = 95%-98%) for Moderna, and 84% (95% CI = 64%-93%) for Janssen vaccine products. Effectiveness of full vaccination in preventing COVID-19-associated hospitalization among adults aged ≥75 years was 91% (95% CI = 87%-94%) for Pfizer-BioNTech, 96% (95% CI = 93%-98%) for Moderna, and 85% (95% CI = 72%-92%) for Janssen vaccine products. COVID-19 vaccines currently authorized in the United States are highly effective in preventing COVID-19-associated hospitalizations in older adults. In light of real-world data demonstrating high effectiveness of COVID-19 vaccines among older adults, efforts to increase vaccination coverage in this age group are critical to reducing the risk for COVID-19-related hospitalization.

Hospitalization of Adolescents Aged 12-17 Years with Laboratory-Confirmed COVID-19 - COVID-NET, 14 States, March 1, 2020-April 24, 2021

Most COVID-19-associated hospitalizations occur in older adults, but severe disease that requires hospitalization occurs in all age groups, including adolescents aged 12-17 years (1). On May 10, 2021, the Food and Drug Administration expanded the Emergency Use Authorization for Pfizer-BioNTech COVID-19 vaccine to include persons aged 12-15 years, and CDC's Advisory Committee on Immunization Practices recommended it for this age group on May 12, 2021.* Before that time, COVID-19 vaccines had been available only to persons aged ≥16 years. Understanding and describing the epidemiology of COVID-19-associated hospitalizations in adolescents and comparing it with adolescent hospitalizations associated with other vaccine-preventable respiratory viruses, such as influenza, offers evidence of the benefits of expanding the recommended age range for vaccination and provides a baseline and context from which to assess vaccination impact. Using the Coronavirus Disease 2019-Associated Hospitalization Surveillance Network (COVID-NET), CDC examined COVID-19-associated hospitalizations among adolescents aged 12-17 years, including demographic and clinical characteristics of adolescents admitted during January 1-March 31, 2021, and hospitalization rates (hospitalizations per 100,000 persons) among adolescents during March 1, 2020-April 24, 2021. Among 204 adolescents who were likely hospitalized primarily for COVID-19 during January 1-March 31, 2021, 31.4% were admitted to an intensive care unit (ICU), and 4.9% required invasive mechanical ventilation; there were no associated deaths. During March 1, 2020-April 24, 2021, weekly adolescent hospitalization rates peaked at 2.1 per 100,000 in early January 2021, declined to 0.6 in mid-March, and then rose to 1.3 in April. Cumulative COVID-19-associated hospitalization rates during October 1, 2020-April 24, 2021, were 2.5-3.0 times higher than were influenza-associated hospitalization rates from three recent influenza seasons (2017-18, 2018-19, and 2019-20) obtained from the Influenza Hospitalization Surveillance Network (FluSurv-NET). Recent increased COVID-19-associated hospitalization rates in March and April 2021 and the potential for severe disease in adolescents reinforce the importance of continued COVID-19 prevention measures, including vaccination and correct and consistent wearing of masks by persons not yet fully vaccinated or when required by laws, rules, or regulations.^†.

Risk Factors for Coronavirus Disease 2019 (COVID-19)-Associated Hospitalization: COVID-19-Associated Hospitalization Surveillance Network and Behavioral Risk Factor Surveillance System

Background

Data on risk factors for COVID-19-associated hospitalization are needed to guide prevention efforts and clinical care. We sought to identify factors independently associated with COVID-19-associated hospitalizations

Methods

U.S. community-dwelling adults (≥18 years) hospitalized with laboratory-confirmed COVID-19 during March 1–June 23, 2020 were identified from the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), a multi-state surveillance system. To calculate hospitalization rates by age, sex, and race/ethnicity strata, COVID-NET data served as the numerator and Behavioral Risk Factor Surveillance System estimates served as the population denominator for characteristics of interest. Underlying medical conditions examined included hypertension, coronary artery disease, history of stroke, diabetes, obesity [BMI ≥30 kg/m ²], severe obesity [BMI≥40 kg/m ²], chronic kidney disease, asthma, and chronic obstructive pulmonary disease. Generalized Poisson regression models were used to calculate adjusted rate ratios (aRR) for hospitalization

Results

Among 5,416 adults, hospitalization rates were higher among those with ≥3 underlying conditions (versus without)(aRR: 5.0; 95%CI: 3.9, 6.3), severe obesity (aRR:4.4; 95%CI: 3.4, 5.7), chronic kidney disease (aRR:4.0; 95%CI: 3.0, 5.2), diabetes (aRR:3.2; 95%CI: 2.5, 4.1), obesity (aRR:2.9; 95%CI: 2.3, 3.5), hypertension (aRR:2.8; 95%CI: 2.3, 3.4), and asthma (aRR:1.4; 95%CI: 1.1, 1.7), after adjusting for age, sex, and race/ethnicity. Adjusting for the presence of an individual underlying medical condition, higher hospitalization rates were observed for adults aged ≥65, 45-64 (versus 18-44 years), males (versus females), and non-Hispanic black and other race/ethnicities (versus non-Hispanic whites)

Conclusion

Our findings elucidate groups with higher hospitalization risk that may benefit from targeted preventive and therapeutic interventions

Characteristics of Adults Aged 18-49 Years Without Underlying Conditions Hospitalized With Laboratory-Confirmed Coronavirus Disease 2019 in the United States: COVID-NET-March-August 2020

Among 513 adults aged 18-49 years without underlying medical conditions hospitalized with coronavirus disease 2019 (COVID-19) during March 2020-August 2020, 22% were admitted to an intensive care unit, 10% required mechanical ventilation, and 3 patients died (0.6%). These data demonstrate that healthy younger adults can develop severe COVID-19.

COVID-19-Associated Hospitalizations Among Health Care Personnel - COVID-NET, 13 States, March 1-May 31, 2020

Health care personnel (HCP) can be exposed to SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), both within and outside the workplace, increasing their risk for infection. Among 6,760 adults hospitalized during March 1-May 31, 2020, for whom HCP status was determined by the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), 5.9% were HCP. Nursing-related occupations (36.3%) represented the largest proportion of HCP hospitalized with COVID-19. Median age of hospitalized HCP was 49 years, and 89.8% had at least one underlying medical condition, of which obesity was most commonly reported (72.5%). A substantial proportion of HCP with COVID-19 had indicators of severe disease: 27.5% were admitted to an intensive care unit (ICU), 15.8% required invasive mechanical ventilation, and 4.2% died during hospitalization. HCP can have severe COVID-19-associated illness, highlighting the need for continued infection prevention and control in health care settings as well as community mitigation efforts to reduce transmission.

Multistate analysis of prospective Legionnaires' disease cluster detection using SaTScan, 2011-2015

Detection of clusters of Legionnaires’ disease, a leading waterborne cause of pneumonia, is challenging. Clusters vary in size and scope, are associated with a diverse range of aerosol-producing devices, including exposures such as whirlpool spas and hotel water systems typically associated with travel, and can occur without an easily identified exposure source. Recently, jurisdictions have begun to use SaTScan spatio-temporal analysis software prospectively as part of routine cluster surveillance. We used data collected by the Active Bacterial Core surveillance platform to assess the ability of SaTScan to detect Legionnaires’ disease clusters. We found that SaTScan analysis using traditional surveillance data and geocoded residential addresses was unable to detect many common Legionnaires’ disease cluster types, such as those associated with travel or a prolonged time between cases. Additionally, signals from an analysis designed to simulate a real-time search for clusters did not align with clusters identified by traditional surveillance methods or a retrospective SaTScan analysis. A geospatial analysis platform better tailored to the unique characteristics of Legionnaires’ disease epidemiology would improve cluster detection and decrease time to public health action.

Targeted Curing of All Lysogenic Bacteriophage from Streptococcus pyogenes Using a Novel Counter-selection Technique

Streptococcus pyogenes is a human commensal and a bacterial pathogen responsible for a wide variety of human diseases differing in symptoms, severity, and tissue tropism. The completed genome sequences of >37 strains of S. pyogenes, representing diverse disease-causing serotypes, have been published. The greatest genetic variation among these strains is attributed to numerous integrated prophage and prophage-like elements, encoding several virulence factors. A comparison of isogenic strains, differing in prophage content, would reveal the effects of these elements on streptococcal pathogenesis. However, curing strains of prophage is often difficult and sometimes unattainable. We have applied a novel counter-selection approach to identify rare S. pyogenes mutants spontaneously cured of select prophage. To accomplish this, we first inserted a two-gene cassette containing a gene for kanamycin resistance (Kan^R) and the rpsL wild-type gene, responsible for dominant streptomycin sensitivity (Sm^S), into a targeted prophage on the chromosome of a streptomycin resistant (Sm^R) mutant of S. pyogenes strain SF370. We then applied antibiotic counter-selection for the re-establishment of the Kan^S/Sm^R phenotype to select for isolates cured of targeted prophage. This methodology allowed for the precise selection of spontaneous phage loss and restoration of the natural phage attB attachment sites for all four prophage-like elements in this S. pyogenes chromosome. Overall, 15 mutants were constructed that encompassed every permutation of phage knockout as well as a mutant strain, named CEM1ΔΦ, completely cured of all bacteriophage elements (a ~10% loss of the genome); the only reported S. pyogenes strain free of prophage-like elements. We compared CEM1ΔΦ to the WT strain by analyzing differences in secreted DNase activity, as well as lytic and lysogenic potential. These mutant strains should allow for the direct examination of bacteriophage relationships within S. pyogenes and further elucidate how the presence of prophage may affect overall streptococcal survival, pathogenicity, and evolution.

Statin treatment and mortality: propensity score-matched analyses of 2007-2008 and 2009-2010 laboratory-confirmed influenza hospitalizations

Background.  Annual influenza epidemics are responsible for substantial morbidity and mortality. The use of immunomodulatory agents such as statins to target host inflammatory responses in influenza virus infection has been suggested as an adjunct treatment, especially during pandemics, when antiviral quantities are limited or vaccine production can be delayed. Methods.  We used population-based, influenza hospitalization surveillance data, propensity score-matched analysis, and Cox regression to determine whether there was an association between mortality (within 30 days of a positive influenza test) and statin treatment among hospitalized cohorts from 2 influenza seasons (October 1, 2007 to April 30, 2008 and September 1, 2009 to April 31, 2010). Results.  Hazard ratios for death within the 30-day follow-up period were 0.41 (95% confidence interval [CI], .25-.68) for a matched sample from the 2007-2008 season and 0.77 (95% CI, .43-1.36) for a matched sample from the 2009 pandemic. Conclusions.  The analysis suggests a protective effect against death from influenza among patients hospitalized in 2007-2008 but not during the pandemic. Sensitivity analysis indicates the findings for 2007-2008 may be influenced by unmeasured confounders. This analysis does not support using statins as an adjunct treatment for preventing death among persons hospitalized for influenza.

Observational study of spinal muscular atrophy type I and implications for clinical trials

OBJECTIVES

Prospective cohort study to characterize the clinical features and course of spinal muscular atrophy type I (SMA-I).

METHODS

Patients were enrolled at 3 study sites and followed for up to 36 months with serial clinical, motor function, laboratory, and electrophysiologic outcome assessments. Intervention was determined by published standard of care guidelines. Palliative care options were offered.

RESULTS

Thirty-four of 54 eligible subjects with SMA-I (63%) enrolled and 50% of these completed at least 12 months of follow-up. The median age at reaching the combined endpoint of death or requiring at least 16 hours/day of ventilation support was 13.5 months (interquartile range 8.1-22.0 months). Requirement for nutritional support preceded that for ventilation support. The distribution of age at reaching the combined endpoint was similar for subjects with SMA-I who had symptom onset before 3 months and after 3 months of age (p=0.58). Having 2 SMN2 copies was associated with greater morbidity and mortality than having 3 copies. Baseline electrophysiologic measures indicated substantial motor neuron loss. By comparison, subjects with SMA-II who lost sitting ability (n=10) had higher motor function, motor unit number estimate and compound motor action potential, longer survival, and later age when feeding or ventilation support was required. The mean rate of decline in The Children's Hospital of Philadelphia Infant Test for Neuromuscular Disorders motor function scale was 1.27 points/year (95% confidence interval 0.21-2.33, p=0.02).

CONCLUSIONS

Infants with SMA-I can be effectively enrolled and retained in a 12-month natural history study until a majority reach the combined endpoint. These outcome data can be used for clinical trial design.

Prospective cohort study of spinal muscular atrophy types 2 and 3

OBJECTIVE

To characterize the natural history of spinal muscular atrophy type 2 and type 3 (SMA 2/3) beyond 1 year and to report data on clinical and biological outcomes for use in trial planning.

METHODS

We conducted a prospective observational cohort study of 79 children and young adults with SMA 2/3 who participated in evaluations for up to 48 months. Clinically, we evaluated motor and pulmonary function, quality of life, and muscle strength. We also measured SMN2 copy number, hematologic and biochemical profiles, muscle mass by dual x-ray absorptiometry (DXA), and the compound motor action potential (CMAP) in a hand muscle. Data were analyzed for associations between clinical and biological/laboratory characteristics cross-sectionally, and for change over time in outcomes using all available data.

RESULTS

In cross-sectional analyses, certain biological measures (specifically, CMAP, DXA fat-free mass index, and SMN2 copy number) and muscle strength measures were associated with motor function. Motor and pulmonary function declined over time, particularly at time points beyond 12 months of follow-up.

CONCLUSION

The intermediate and mild phenotypes of SMA show slow functional declines when observation periods exceed 1 year. Whole body muscle mass, hand muscle compound motor action potentials, and muscle strength are associated with clinical measures of motor function. The data from this study will be useful for clinical trial planning and suggest that CMAP and DXA warrant further evaluation as potential biomarkers.

Spinal muscular atrophy type III: trying to understand subtle functional change over time--a case report

Spinal muscular atrophy is a relatively stable chronic disease. Patients may gradually experience declines in muscle strength and motor function over time. However, functional progression is difficult to document, and the mechanism remains poorly understood. An 11-year-old girl was diagnosed at 19 months and took a few steps without assistance at 25 months. She was evaluated for 54 months in a prospective multicenter natural history study. Outcome measures were performed serially. From 6 to 7.5 years, motor function improved. From 7.5 to 11 years, motor function declined with increasing growth. Manual muscle testing scores minimally decreased. Motor unit number estimation studies gradually increased over 4.5 years. Compared to the published natural history of spinal muscular atrophy type III, our patient lost motor function over time. However, she walked with assistance 2 years longer than expected. Our report highlights possible precipitating factors that could affect the natural history of spinal muscular atrophy type III.

Successful establishment of Wolbachia in Aedes populations to suppress dengue transmission

Genetic manipulations of insect populations for pest control have been advocated for some time, but there are few cases where manipulated individuals have been released in the field and no cases where they have successfully invaded target populations. Population transformation using the intracellular bacterium Wolbachia is particularly attractive because this maternally-inherited agent provides a powerful mechanism to invade natural populations through cytoplasmic incompatibility. When Wolbachia are introduced into mosquitoes, they interfere with pathogen transmission and influence key life history traits such as lifespan. Here we describe how the wMel Wolbachia infection, introduced into the dengue vector Aedes aegypti from Drosophila melanogaster, successfully invaded two natural A. aegypti populations in Australia, reaching near-fixation in a few months following releases of wMel-infected A. aegypti adults. Models with plausible parameter values indicate that Wolbachia-infected mosquitoes suffered relatively small fitness costs, leading to an unstable equilibrium frequency <30% that must be exceeded for invasion. These findings demonstrate that Wolbachia-based strategies can be deployed as a practical approach to dengue suppression with potential for area-wide implementation.

Observational study of spinal muscular atrophy type 2 and 3: functional outcomes over 1 year

OBJECTIVE

To characterize the short-term course of spinal muscular atrophy (SMA) in a genetically and clinically well-defined cohort of patients with SMA.

DESIGN

A comprehensive multicenter, longitudinal, observational study.

SETTING

The Pediatric Neuromuscular Clinical Research Network for SMA, a consortium of clinical investigators at 3 clinical sites.

PARTICIPANTS

Sixty-five participants with SMA types 2 and 3, aged 20 months to 45 years, were prospectively evaluated.

INTERVENTION

We collected demographic and medical history information and determined the SMN 2 copy number.

MAIN OUTCOME MEASURES

Clinical outcomes included measures of motor function (Gross Motor Function Measure and expanded Hammersmith Functional Motor Scale), pulmonary function (forced vital capacity), and muscle strength (myometry). Participants were evaluated every 2 months for the initial 6 months and every 3 months for the subsequent 6 months. We evaluated change over 12 months for all clinical outcomes and examined potential correlates of change over time including age, sex, SMA type, ambulatory status, SMN2 copy number, medication use, and baseline function.

RESULTS

There were no significant changes over 12 months in motor function, pulmonary function, and muscle strength measures. There was evidence of motor function gain in ambulatory patients, especially in those children younger than 5 years. Scoliosis surgery during the observation period led to a subsequent decline in motor function.

CONCLUSIONS

Our results confirm previous clinical reports suggesting that SMA types 2 and 3 represent chronic phenotypes that have relatively stable clinical courses. We did not detect any measurable clinical disease progression in SMA types 2 and 3 over 12 months, suggesting that clinical trials will have to be designed to measure improvement rather than stabilization of disease progression.

Risk factors for sporadic shigellosis, FoodNet 2005

BACKGROUND

An estimated 450,000 cases of shigellosis occur annually in the United States. Outbreaks have been associated with food, water, child daycare centers, and men who have sex with men. However, for sporadic infections, which account for the majority of cases, risk exposures are poorly characterized.

METHODS

Foodborne Diseases Active Surveillance Network (FoodNet) conducts active, laboratory-based shigellosis surveillance in 10 US sites. We interviewed cases with illness onset during 2005 about exposures during the week before symptom onset using a standardized questionnaire. The proportion of patients who denied nonfood risks was used to estimate the burden attributable to foodborne transmission.

RESULTS

Overall, 1494 cases were identified. The approximate incidence was 3.9/100,000, with the highest rates among children aged 1-4 years (16.4) and Hispanics (8.4). Of the 929 cases interviewed, 223 (24%) reported international travel in the week before symptom onset. Of the 626 nontraveling cases with complete risk factor information, 298 (48%) reported exposure to daycare or a household member with diarrhea; 99 (16%) reported drinking untreated water or recreational exposure to water; and 16 (3%) reported sexual contact with a person with diarrhea. Two hundred and fifty-nine (41%) denied all nonfood exposures examined.

CONCLUSIONS

Sporadic shigellosis is most common among young children and Hispanics. Common exposures include international travel and contact with ill persons or daycare. However, more than one-third of US shigellosis cases annually might be due to food consumed in the United States.

Physician attitudes: electronic medical records in ambulatory care

This is a survey study to evaluate physician opinions regarding the impact of implementing an electronic medical record (EMR) on basic functions of clinical care. Opinions were evaluated using a uniquely designed survey both prior to implementation of the EMR as well as afterward to see anticipated vs. actual impact of this change. Valuable information was gathered on transition and training. The subjects were primarily residents at an Internal Medicine/Pediatrics primary care clinic.

Novel algorithms reveal streptococcal transcriptomes and clues about undefined genes

Bacteria-host interactions are dynamic processes, and understanding transcriptional responses that directly or indirectly regulate the expression of genes involved in initial infection stages would illuminate the molecular events that result in host colonization. We used oligonucleotide microarrays to monitor (in vitro) differential gene expression in group A streptococci during pharyngeal cell adherence, the first overt infection stage. We present neighbor clustering, a new computational method for further analyzing bacterial microarray data that combines two informative characteristics of bacterial genes that share common function or regulation: (1) similar gene expression profiles (i.e., co-expression); and (2) physical proximity of genes on the chromosome. This method identifies statistically significant clusters of co-expressed gene neighbors that potentially share common function or regulation by coupling statistically analyzed gene expression profiles with the chromosomal position of genes. We applied this method to our own data and to those of others, and we show that it identified a greater number of differentially expressed genes, facilitating the reconstruction of more multimeric proteins and complete metabolic pathways than would have been possible without its application. We assessed the biological significance of two identified genes by assaying deletion mutants for adherence in vitro and show that neighbor clustering indeed provides biologically relevant data. Neighbor clustering provides a more comprehensive view of the molecular responses of streptococci during pharyngeal cell adherence.

Evaluations of mosquito age grading techniques based on morphological changes

Evaluations were made of the accuracy and practicality of mosquito age grading methods based on changes to mosquito morphology; including the Detinova ovarian tracheation, midgut meconium, Polovodova ovariole dilatation, ovarian injection, and daily growth line methods. Laboratory maintained Aedes vigilax (Skuse) and Culex annulirostris (Skuse) females of known chronological and physiological ages were used for these assessments. Application of the Detinova technique to laboratory reared Ae. vigilax females in a blinded trial enabled the successful identification of nulliparous and parous females in 83.7-89.8% of specimens. The success rate for identifying nulliparous females increased to 87.8-98.0% when observations of ovarian tracheation were combined with observations of the presence of midgut meconium. However, application of the Polovodova method only enabled 57.5% of nulliparous, 1-parous, 2-parous, and 3-parous Ae. vigilax females to be correctly classified, and ovarian injections were found to be unfeasible. Poor correlation was observed between the number of growth lines per phragma and the calendar age of laboratory reared Ae. vigilax females. In summary, morphological age grading methods that offer simple two-category predictions (ovarian tracheation and midgut meconium methods) were found to provide high-accuracy classifications, whereas methods that offer the separation of multiple age categories (ovariolar dilatation and growth line methods) were found to be extremely difficult and of low accuracy. The usefulness of the morphology-based methods is discussed in view of the availability of new mosquito age grading techniques based on cuticular hydrocarbon and gene transcription changes.

Evaluations of mosquito age grading techniques based on morphological changes

Evaluations were made of the accuracy and practicality of mosquito age grading methods based on changes to mosquito morphology; including the Detinova ovarian tracheation, midgut meconium, Polovodova ovariole dilatation, ovarian injection, and daily growth line methods. Laboratory maintained Aedes vigilax (Skuse) and Culex annulirostris (Skuse) females of known chronological and physiological ages were used for these assessments. Application of the Detinova technique to laboratory reared Ae. vigilax females in a blinded trial enabled the successful identification of nulliparous and parous females in 83.7-89.8% of specimens. The success rate for identifying nulliparous females increased to 87.8-98.0% when observations of ovarian tracheation were combined with observations of the presence of midgut meconium. However, application of the Polovodova method only enabled 57.5% of nulliparous, 1-parous, 2-parous, and 3-parous Ae. vigilax females to be correctly classified, and ovarian injections were found to be unfeasible. Poor correlation was observed between the number of growth lines per phragma and the calendar age of laboratory reared Ae. vigilax females. In summary, morphological age grading methods that offer simple two-category predictions (ovarian tracheation and midgut meconium methods) were found to provide high-accuracy classifications, whereas methods that offer the separation of multiple age categories (ovariolar dilatation and growth line methods) were found to be extremely difficult and of low accuracy. The usefulness of the morphology-based methods is discussed in view of the availability of new mosquito age grading techniques based on cuticular hydrocarbon and gene transcription changes.

An expanded version of the Hammersmith Functional Motor Scale for SMA II and III patients

PURPOSE

To develop and evaluate an expanded version of the Hammersmith Functional Motor Scale allowing for evaluation of ambulatory SMA patients.

PROCEDURES

Thirty-eight patients with SMA type II or III were evaluated using the Gross Motor Function Measure and the Hammersmith Functional Motor Scale. Based on statistical and clinical criteria, we selected 13 Gross Motor Function Measure items to develop an expanded HFMS. The expanded Hammersmith Functional Motor Scale was validated by comparison with the Gross Motor Function Measure minus the 13 items (GMFM-75) and an assessment of clinical function. The reliability of the expanded Hammersmith Functional Motor Scale in 36 patients was established.

FINDINGS

The expanded Hammersmith Functional Motor Scale was highly correlated with the GMFM-75 and the clinical function assessment (p=0.97, and p=0.90). The expanded Hammersmith Functional Motor Scale showed excellent test-retest reliability (International Coordinating Committee = 0.99).

CONCLUSIONS

The expanded Hammersmith Functional Motor Scale allows assessment of high functioning SMA type II and III patients. Ease of administration and correlation with established motor function measures justify use in future SMA clinical trials.

Sublethal effects of mosquito larvicides on swimming performance of larvivorous fish Melanotaenia duboulayi (Atheriniformes: Melanotaeniidae)

Laboratory studies were conducted to determine the sublethal effects of exposure to selected larvicides on the critical swimming speed (Ucrit) of crimson-spotted rainbowfish, Melanotaenia duboulayi (Castlenau). This native fish is common throughout southeastern Queensland, and it is increasingly being distributed as a biological control agent of mosquitoes. The selected larvicides included, two organophosphate (OP) compounds (temephos and pirimiphos-methyl), two microbial larvicides (Bacillus thuringiensis spp. israelensis [Bti] de Barjac and Bacillus sphaericus [Bs] Neide), and an insect growth regulator (IGR) (s-methoprene). Exposure to the OP temephos at 10 times the effective field concentration (EFC; 0.33 mg/liter), and OP pirimiphos-methyl at the EFC (0.50 mg/liter), resulted in a significant reduction in the Ucrit of M. duboulayi under controlled conditions. Conversely, exposure to the microbial (Bti and Bs) and IGR (s-methoprene) larvicides at 10 times the EFC had no effect on the Ucrit of M. duboulayi. Accordingly, these products are suitable for integrated pest management programs in Australia.

M.SpyI, a DNA methyltransferase encoded on a mefA chimeric element, modifies the genome of Streptococcus pyogenes

While screening the clonality of Streptococcus pyogenes isolates from an outbreak of erythromycin-resistant pharyngitis in Pittsburgh, PA, we found a correlation between the presence of the chimeric element Phi10394.4 (carrying the macrolide efflux gene, mefA) and genomic DNA being resistant to cleavage by SmaI restriction endonuclease. A search of the open reading frames in Phi10394.4 identified a putative type II restriction-modification (R-M) cassette containing a cytosine methyltransferase gene (spyIM). Heterologous expression of the cloned spyIM gene, as well as allelic-replacement experiments, showed that the action of this methyltransferase (M.SpyI) was responsible for the inhibition of SmaI digestion of genomic DNA in the Phi10394.4-containing isolates. Analysis of the methylation patterns of streptococcal genomic DNA from spyIM-positive strains, a spyIM deletion mutant, and a spyIM-negative strain determined that M.SpyI specifically recognized and methylated the DNA sequence to generate 5'-C(m)CNGG. To our knowledge, this is the first methyltransferase gene from S. pyogenes to be cloned and to have its activity characterized. These results reveal why pulsed field gel electrophoresis analysis of SmaI-digested genomic DNA cannot be used to analyze the clonality of some streptococci containing Phi10394.4 and may explain the inability of previous epidemiological studies to use SmaI to analyze DNAs from macrolide-resistant streptococci. The presence of the SpyI R-M cassette in Phi10394.4 could impart a selective advantage to host strain survival and may provide another explanation for the observed increase in macrolide-resistant streptococci.

Ross River virus disease clusters and spatial relationship with mosquito biting exposure in Redland Shire, southern Queensland, Australia

The spatial heterogeneity in the risk of Ross River virus (family Togaviridae, genus Alphavirus, RRV) disease, the most common mosquito-borne disease in Australia, was examined in Redland Shire in southern Queensland, Australia. Disease cases, complaints from residents of intense mosquito biting exposure, and human population data were mapped using a geographic information system. Surface maps of RRV disease age-sex standardized morbidity ratios and mosquito biting complaint morbidity ratios were created. To determine whether there was significant spatial variation in disease and complaint patterns, a spatial scan analysis method was used to test whether the number of cases and complaints was distributed according to underlying population at risk. Several noncontiguous areas in proximity to productive saline water habitats of Aedes vigilax (Skuse), a recognized vector of RRV, had higher than expected numbers of RRV disease cases and complaints. Disease rates in human populations in areas which had high numbers of adult Ae. vigilax in carbon dioxide- and octenol-baited light traps were up to 2.9 times those in areas that rarely had high numbers of mosquitoes. It was estimated that targeted control of adult Ae. vigilax in these high-risk areas could potentially reduce the RRV disease incidence by an average of 13.6%. Spatial correlation was found between RRV disease risk and complaints from residents of mosquito biting. Based on historical patterns of RRV transmission throughout Redland Shire and estimated future human population growth in areas with higher than average RRV disease incidence, it was estimated that RRV incidence rates will increase by 8% between 2001 and 2021. The use of arbitrary administrative areas that ranged in size from 4.6 to 318.3 km2 has the potential to mask any small scale heterogeneity in disease patterns. With the availability of georeferenced data sets and high-resolution imagery, it is becoming more feasible to undertake spatial analyses at relatively small scales.

Analysis of Barmah Forest virus disease activity in Queensland, Australia, 1993-2003: identification of a large, isolated outbreak of disease

Barmah Forest virus (BFV) disease is the second most common mosquito-borne disease in Australia. Although the majority of notifications are received from Queensland, little is known about the distribution of the disease within the state, or the important mosquito vectors and nonhuman vertebrate hosts. We conducted a retrospective statistical analysis of the notifications received from Queensland residents from 1993 to 2003 to establish long-term local incidence rates and to identify disease outbreaks. In total, 4,544 notifications were received over the 10-yr period. Disease reporting peaked in autumn, although the peak transmission season encompassed both summer and autumn. Long-term standardized incidence rates for summer/autumn and winter/spring varied across the state, showing positive spatial autocorrelation in both 6-mo periods. Although 15 instances of increased disease activity were identified, only one major disease outbreak affecting eight contiguous local government areas was detected in summer/autumn 2002/2003. This outbreak contained 297 cases, 115 more than would be expected over this period. The factors important to this outbreak are unknown and require further investigation. Although the incidence rates for BFV disease are lower than Ross River virus disease, the most reported mosquito-borne disease in Australia, several factors indicate that this virus should be considered an important public health risk in Queensland. These include consistent endemic transmission, apparent underreporting of the disease, and the potential for outbreaks in major population centers.

Self-organization of carbide superlattice and nucleation of carbon nanotubes

In metal-carbon systems with known stable compounds, carbide nanocrystals self-organize epitaxially on metal surfaces to form two-dimensional arrays during carbon deposition. The process is energetically driven by the competition between the strain and surface energies, and it appears to play an important role in the nucleation of single-walled carbon nanotubes. Interplay between energetics and kinetics controls carbon precipitation from the superlattice, such that the length scale of the carbide and superlattice appears to control the size and morphology of the precipitates. Furthermore, carbon precipitates appear to be "seedlings" of carbon nanotubes grown on top of the carbide nanocrystals. These findings reveal that the nucleation of carbon nanotubes is a nonequilibrium process and that a stable carbide superlattice can be used as an ordered template of carbon saturated "roots" for nucleating nanotube bundles with controlled diameter, spacing, and perhaps chirality.

Self-organization of carbide superlattice and nucleation of carbon nanotubes

In metal-carbon systems with known stable compounds, carbide nanocrystals self-organize epitaxially on metal surfaces to form two-dimensional arrays during carbon deposition. The process is energetically driven by the competition between the strain and surface energies, and it appears to play an important role in the nucleation of single-walled carbon nanotubes. Interplay between energetics and kinetics controls carbon precipitation from the superlattice, such that the length scale of the carbide and superlattice appears to control the size and morphology of the precipitates. Furthermore, carbon precipitates appear to be "seedlings" of carbon nanotubes grown on top of the carbide nanocrystals. These findings reveal that the nucleation of carbon nanotubes is a nonequilibrium process and that a stable carbide superlattice can be used as an ordered template of carbon saturated "roots" for nucleating nanotube bundles with controlled diameter, spacing, and perhaps chirality.

Enhanced vector competence of Aedes aegypti (Diptera: Culicidae) from the Torres Strait compared with mainland Australia for dengue 2 and 4 viruses

Australian Aedes aegypti (L.) mosquitoes colonized from the Torres Strait and three mainland localities (Charters Towers, Townsville, and Cairns) were fed on blood suspensions containing dengue virus type 2 (DEN-2) or dengue virus type 4 (DEN-4). Variation was found in oral susceptibility to DEN-2 (59 -99% infection) and DEN-4 (28-79% infection) among Ae. aegypti assayed for virus at 8, 12, 16, or 20 d after ingestion of infected blood. Torres Strait Ae. aegypti were the most susceptible to DEN-2 and were significantly more efficient in transmission to capillary tube at 16 d (76% transmission) than mainland Ae. aegypti populations (20-28% transmission). Torres Strait Ae. aegypti were also the most susceptible to DEN-4, although transmission did not vary significantly from mainland populations at 16 d (12% compared with 0-4%) or 20 d (16% compared with 4-16%). Disseminated infection (i.e., leg infection) with either DEN-2 or DEN-4 was not an accurate predictor of transmission potential. This study demonstrates differences among Australian Ae. aegypti populations in vector competence for DEN-2 and DEN-4. Torres Strait Ae. aegypti were more frequently infected and able to transmit DEN-2 at higher rates than mainland populations. These data indicate that the Torres Strait region is potentially more receptive to dengue transmission than mainland localities, a finding discussed with respect to past outbreaks.

Autogeny in Ochlerotatus vigilax (Diptera: Culicidae) from southeast Queensland, Australia

Field and laboratory investigations were undertaken to determine the level of expression of autogeny in the mosquito Ochlerotatus vigilax (Skuse) from southeast Queensland, Australia, and whether there was evidence of seasonal variation. At two field sites in southeast Queensland, Wellington Point and Donnybrook, autogeny rates were determined on six occasions between January 2001 and January 2002. The autogeny rate varied between 71 and 100% at Wellington Point and between 63 and 100% at Donnybrook. Autogenous fecundity ranged from 17 to 63 eggs per female at Wellington Point and from 13 to 88 eggs per female at Donnybrook. Positive relationships were found between adult body size (indicated by wing length), autogeny rate, and fecundity. A laboratory study was conducted to investigate the influence of larval nutrition and adult diet (water versus sucrose) on the expression of autogeny. The autogeny rate at a low-diet treatment was between 73 and 90% when sucrose was withheld from females and 100% when sucrose was provided. All high-diet females were autogenous. Autogenous egg development required 80 +/- 6 h from emergence at 27 degrees C. We conclude that autogeny rates are consistently high in Oc. vigilax from the southeast Queensland region.

Self-organization of a carbide superlattice during deposition of carbon on Mo

Formation and evolution of a carbide superlattice (SL) during C deposition on Mo have been studied using molecular beam epitaxy techniques. The ordering of the SL is energetically driven, such that the interplay between strain and surface energies determines the length scale of the SL. Surface precipitation of C occurs within a narrow range of SL spacing that appears to control the size and spacing of the precipitates leading to a possible mechanism for nucleation of single-walled carbon nanotubes.

Winter intervention against Aedes aegypti (Diptera: Culicidae) larvae in subterranean habitats slows surface recolonization in summer

At semiarid Charters Towers, north Queensland, Australia, the importance of Aedes aegypti (L.) in wells was assessed in relation to the colonization of surface habitats during the wet season. From April to July 1999, 10 wells (five positive for Ae. aegypti) were monitored to assess their status and larvae population numbers therein. All surface containers located within a 100 m radius of each well were removed, treated with s-methoprene or sealed to prevent the utilization of these containers by mosquitoes. These inner cores were surrounded by outer zones for a further 100 m in which surface containers were left untreated but all subterranean habitats were treated. Ovitraps were monitored monthly in the inner cores for 36 wk from August 1999 to April 2000 and differences in the proportions of ovitraps positive for Ae. aegypti and Ochlerotatus notoscriptus (Skuse) were analyzed by logistic regression. Analysis of the proportions of ovitraps positive for Ae. aegypti near positive wells indicated significantly greater colonization from November to March (the wet season), compared with those situated near Ae. aegypti negative wells. As Oc. notoscriptus were not produced from subterranean sites, comparisons of the proportions of ovitraps positive for Oc. notoscriptus in positive and negative inner cores provided an indication of the relative productivity of the uncontrolled surface containers in the outer zones. Differences in the utililization of ovitraps by Oc. notoscriptus among positive and negative cores were observed during only one month (March), when oviposition was greater in ovitraps in the negative cores, compared with the positive cores. Best subsets linear regression analysis of the proportion of ovitraps positive forAe. aegypti against meteorological variables (rainfall, mean wind speed, mean relative humidity, mean minimum, and maximum temperature) during the week of ovitrapping indicated that minimum temperature and wind speed accounted for 63.4% of the variability. This study confirms that for semiarid towns such as Charters Towers, the practice of treating a relatively small number of key subterranean habitats during winter will significantly affect Ae. aegypti recolonization of surface container habitats during summer, the period of greatest risk for dengue.

Group A streptococci bind to mucin and human pharyngeal cells through sialic acid-containing receptors

The first step in the colonization of group A streptococci (Streptococcus pyogenes) is adherence to pharyngeal epithelial cells. Prior to adherence to their target tissue, the first barrier that the streptococci encounter is the mucous layer of the respiratory tract. The present study was undertaken to characterize the interaction between mucin, the major glycoprotein component of mucus, and streptococci. We report here that S. pyogenes is able to bind to bovine submaxillary mucin in solid-phase microtiter plate assays. Western blots probed with (125)I-labeled mucin and a panel of monoclonal antibodies revealed that the streptococcal M protein is one of two cell wall-associated proteins responsible for this binding. The binding was further localized to the N-terminal portion of the M molecule. Further analysis revealed that the M protein binds to the sialic acid moieties on mucin, and this interaction seems to be based on M-protein conformation rather than specific amino acid sequences. We found that sialic acid also plays a critical role in the adherence of an M6 streptococcal strain to the Detroit 562 human pharyngeal cell line and have identified alpha2-6-linked sialic acid as an important sialylated linkage for M-protein recognition. Western blot analysis of extracted pharyngeal cell membrane proteins identified three potential sialic acid-containing receptors for the M protein. The results are the first to show that sialic acid not only is involved in the binding of the streptococci to mucin but also plays an important role in adherence of group A streptococci to the pharyngeal cell surface.

Experimental evidence for electron channeling in Fe /Aau (100) superlattices

We present transport and structural data from epitaxial (100) and (111) Au/Fe superlattices grown by molecular beam epitaxy. From their analysis, we conclude that an electron channeling mechanism, due to strong specular reflection of the minority spin carrier at the Au/Fe interfaces, is responsible for the high conductivity in the (100) superlattices.

The importance of subterranean mosquito habitat to arbovirus vector control strategies in north Queensland, Australia

In north Queensland, 14 localities were surveyed for mosquito larvae (third and fourth instar) during summer/autumn and winter from 1996 to 1999. Absolute population numbers in subterranean habitats, mainly service manholes and pits (97%) but also some wells, septic tanks, storm drains, and sumps, were expressed as a proportion of total numbers in these sites plus surface sites within a 100-m radius. When correction factors were applied to subterranean samples, the 472,477 larvae mainly of Aedes tremulus (Theobald) group, Aedes notoscriptus (Skuse), and Aedes aegypti (L.) comprised 78% of the total population. In relation to the proportion of the overall immature mosquito population from subterranean habitats (propsub), linear regression coefficients for minimum temperature, relative humidity, and Mesocyclops copepod prevalence were significant for winter data; but for summer, only relative humidity was significant. Linear regression coefficients for Mesocyclops prevalence approached significance (P = 0.061) in summer. When multiple linear regression was used to model propsub, 68% of the variation was accounted for by relative humidity and the prevalence of Mesocyclops. In the drier and cooler towns, increased use of subterranean sites during winter was caused by reduced availability of surface oviposition sites because of the dry season. In the wetter coastal towns, no such restrictions applied and ambient conditions remained more equitable all year round. Mesocyclops were surprisingly common, particularly in these coastal towns. Release of known numbers of Mesocyclops indicated that 3-sweep netting in service manholes was sensitive down to densities of one Mesocyclops per 10 liters, and overall recovery varied from 1 to 4%. In relation to control, service manholes represent a stable habitat for mosquito (7% positive overall) and Mesocyclops populations. If they remained wet, service manholes positive for mosquito immatures or Mesocyclops during summer/autumn had 96% and 85% chance, respectively, of being positive the following winter. Even allowing for the effect of drying, a mosquito-positive manhole had a 79% chance of remaining positive the following winter. In view of the importance of these sites as refuges from adverse ambient conditions, it is proposed that a winter control strategy using Mesocyclops presents a cost-effective control option to reduce the recolonization of surface sites when conditions become more suitable.

Definition of Ross River virus vectors at Maroochy Shire, Australia

Evidence of Ross River (RR) virus infection in field-collected mosquitoes and data from laboratory vector competence experiments incriminated a range of mosquito species as important vectors of RR virus in Maroochy Shire, Queensland, Australia. Nine RR and 2 Barmah Forest virus isolates were recovered from 27,529 mosquitoes collected in light traps from Maroochy Shire during 1996. Nine of the 10 most abundant mosquito species collected in light traps were fed on blood containing the B94/20 strain RR isolated from Queensland in 1994. All species except for Culex sitiens Wiedemann were susceptible to experimental infection. Evidence of RR virus transmission to mice was found with Aedes vigilax (Skuse), Aedes funereus (Theobald), Aedes procax (Skuse), Culex annulirostris Skuse, Mansonia uniformis (Theobald) and Culex australicus Dobrotworsky & Drummond. Aedes notoscriptus (Skuse) and Aedes multiplex (Theobald) were susceptible to RR virus infection, although there was no evidence of virus transmission. Based on adult abundance and vector competence results, freshwater species such as Cx. annulirostris, Ae. procax, and Ae. funereus, and saltmarsh Ae. vigilax, appear to be important vectors of RR virus in Maroochy Shire and control programs should be revised to include these species.

Vector competence of mosquitoes (Diptera: Culicidae) from Maroochy Shire, Australia, for Barmah Forest virus

Mosquitoes were collected in light traps from Maroochy Shire and fed on blood containing the sympatric BF1611 strain of Barmah Forest virus (BF). Saltmarsh Aedes vigilax (Skuse) and freshwater Aedes procax (Skuse) were highly susceptible to infection, with ID50s of 10(1.7) and 10(1.5) African green monkey kidney (Vero) cell culture infectious dose, 50% endpoint (CCID50) per mosquito, respectively, followed by Aedes multiplex (Theobald) and Aedes funereus (Theobald) with 10(2.5) and 10(3.2) CCID50 per mosquito, respectively. Culex australicus Dobrotworsky & Drummond and Mansonia uniformis (Theobald) that were fed 10(3.6) CCID50 (Vero) BF per mosquito had infection rates of 28 and 60%, respectively. Only 8% of freshwater Culex annulirostris Skuse fed the same viral dose were infected. Evidence of virus transmission to mice was found with Ae. vigilax and Ae. procax, with transmission rates of 65 and 88% at 11-12 d after infection, respectively. Based on adult abundance, susceptibility to infection, and efficiency of virus transmission, Ae. vigilax would appear to be the most important vector of BF in Maroochy Shire.

Spatial and temporal analysis of Ross River virus disease patterns at Maroochy Shire, Australia: association between human morbidity and mosquito (Diptera: Culicidae) abundance

Notifications of Ross River (RR) virus disease in Maroochy Shire were mapped according to the patient's place of residence, and standardized morbidity ratios were calculated for each of 11 census districts, with 4 areas having higher than average overall rates of RR virus disease notification. Temporal analysis of RR virus disease notifications from each of the 11 areas indicated that epidemics of RR virus disease either were widespread, resulting in higher than average numbers of cases from the majority of areas, or limited to only certain areas. Mosquitoes were collected in CO2 light traps, and the numbers analyzed to determine whether there was any association between mosquito abundance and disease incidence. Seasonal light trap indices for the fresh water-breeding Culex annulirostris Skuse and brackish water-breeding Aedes funereus (Theobald) were correlated positively with disease incidence. There was no apparent association between Aedes vigilax (Skuse) or Aedes procax (Skuse) light trap indices and disease incidence. Identification of human subpopulations with higher than average rates of RR virus disease, and the mosquito vectors associated with virus transmission, should provide a framework for the development of focused and therefore more effective control programs.

Characteristics of acquired immunodeficiency syndrome in older adults

OBJECTIVE

To examine demographic and clinical features of older AIDS patients in comparison with younger individuals.

DESIGN

Data base review.

SETTING

Maryland AIDS Registry from 1981 through the end of 1994.

PARTICIPANTS

All registered Maryland AIDS cases greater than or equal to 60 years of age at diagnosis and all Maryland AIDS cases aged 20 to 39.

MAIN OUTCOME MEASURES

Demographic features, mode of transmission and change in mode over time, clinical presentations, CD4+ counts, and survival time.

RESULTS

A total of 321 (2.7%) AIDS cases diagnosed in Maryland were people 60 years of age or older compared with 7511 cases (63.9%) in people aged 20 to 39 years. The proportion of whites was higher in the older group, but the gender distribution was similar to younger counterparts. Transfusion was the primary cause of exposure of 32% of the older people with AIDS; however, during the last few years, sexual transmission and drug abuse have been implicated more frequently. Twelve percent of older patients had no reported risk factors compared with 4% of younger AIDS patients. The most common presenting AIDS indicator disease in older cases was Pneumocystis carinii pneumonia. Wasting syndrome, candidiasis, and HIV encephalopathy also occurred frequently. Median life span was 9 months compared with 22 months in the young.

CONCLUSION

Our study demonstrates that transfusion is no longer the leading cause of AIDS in older people in Maryland. The relatively increased prominence of transmission by other modes in this age group raises the importance of preventive and educational measures. Older patients generally have a shorter survival than younger individuals.

Investigation of gray-headed flying foxes (Pteropus poliocephalus) (Megachiroptera: Pteropodidae) and mosquitoes in the ecology of Ross River virus in Australia

Entomologic and virologic factors were investigated to determine whether gray-headed flying foxes (Pteropus poliocephalus) from Indooroopilly Island, Brisbane, Australia could be vertebrate hosts of Ross River (RR) virus. Aedes funereus was the most abundant mosquito species with 6,300-38,700 females per light trap night in the flying fox camp containing gray-headed, black (P. alecto), and little red (P. scapulatus) flying foxes. Sixteen Ae. funereus blood meals from this collection were analyzed by hemoglobin electrophoresis and were found to be from P. alecto. From pledget feeding with RR virus, the infectious dose required to infect 50% of wild caught Ae. funereus was log10 4.2 50% tissue culture infectious doses per mosquito, with a transmission rate to mice of 17% at 9-10 days post infection. Experimental infection of 10 juvenile P. poliocephalus produced viremias of low titer in five animals, with a duration of 1-4 days and a mean of two days. Three percent of colonized Ae. vigilax that fed on the 10 animals during this period became infected. One of the five viremic flying foxes and two of the five aviremic animals produced a detectable immune response by either neutralization or hemagglutination-inhibition tests. Based on the low to moderate vector competence of Ae. funereus for RR virus, and evidence that P. poliocephalus is a poor vertebrate host of RR virus, it is unlikely that RR virus transmission would be maintained between these two species, but it could be maintained by other more competent vector/host pairs.

Molecular cloning and characterization of the genes encoding the L1 and L2 components of hemolysin BL from Bacillus cereus

Hemolysin BL, which is composed of a binding component, B, and two lytic components, L1 and L2, is the enterotoxin responsible for the diarrheal food poisoning syndrome caused by strains of Bacillus cereus. To further characterize the toxin, we sought to clone and sequence the genes encoding the L1 and L2 proteins. A genomic library was screened with polyclonal antibody to the L1 and L2 proteins to identify recombinant clones containing the genes. Five clones reacted with the antibody to L2, but none reacted with the antibody to L1. Southern hybridization analysis with oligonucleotide probes designed from the N-terminal amino acid sequences of the L1 and L2 proteins, in conjunction with immunoblot and nucleotide sequence analysis, revealed that the recombinant plasmid from one of the clones contained two genes, hblC and hblD, which encode L2 and L1, respectively. The two genes are arranged in tandem and are separated by only 37 bases. The gene which encodes the B component of hemolysin BL (hblA) is located immediately downstream from the gene encoding the L1 protein. Northern blot analysis of B. cereus RNA showed a 5.5-kb transcript which hybridized with DNA fragments internal to, or including a portion of, the coding sequences of the B, L1, and L2 genes, suggesting that the clustered genes which encode the components of hemolysin BL are cotranscribed and constitute an operon.

Effects of incontinence care cleansing regimens on skin integrity

Soap and water and a no-rinse cleanser, with and without a moisture barrier, were examined for their effects as cleansing regimens on the perineal skin of 10 older female residents of an extended care facility. Each cleansing regimen was used for 3 weeks, with two weekly measurements obtained for erythema, pH, and transepidermal water loss. Results indicated that soap and water was the least efficacious regimen unless used with a moisture barrier. The no-rinse cleanser was better than soap and water in terms of skin effects and cost savings. The findings suggest that a no-rinse cleanser in conjunction with a moisture barrier is a more skin-preserving and cost-effective incontinence care cleansing regimen than soap and water for older female nursing home residents with incontinence.

Failure of infinite life span human cells from different immortality complementation groups to yield finite life span hybrids

The observation that fusion of infinite life span cells with finite life span cells produces hybrid cells with finite life spans led to the conclusion that an infinite life span in culture is a recessive trait resulting from loss of the function of a gene or genes that contribute to an active program for cellular senescence. Furthermore, finding that certain pairs of infinite life span cells, when fused to one another, can complement each other to yield finite life span hybrids allowed 30 infinite life span cell lines to be assigned to four immortality complementation groups (Pereira-Smith and Smith, 1988, Proc. Natl. Acad. Sci. U.S.A., 85:6042). In the present study, we fused a chromosomally stable, near diploid, morphologically normal, infinite life span cell strain, designated MSU-1.1, with its normal, finite life span, precursor cell strain and obtained finite life span hybrids, as expected if infinite life span in culture is a recessive trait. However, 14 of the 14 hybrids from our fusions of MSU-1.1 cells with representative cell lines from each of the four immortality complementation groups, and 38 of the 39 hybrids from our fusions of infinite life span cells that have been reported to complement each other, failed to exhibit finite life spans. This result suggests that infinite life span cells cannot complement each other to yield finite life span hybrids. In examining this unexpected result, we obtained evidence that long-term dual drug selection can be deleterious to hybrid cells even though they carry resistance markers for both drugs, indicating that the cell death of such hybrids observed in other studies may have resulted from the cytotoxic effect of long-term drug selection, rather than from senescence.