5' copyback defective viral genomes are major component in clinical and non-clinical influenza samples

Clinical samples from people with influenza disease have been analyzed to assess the presence and abundance of Defective Viral Genomes (DVGs), but these have not been assessed using the same bioinformatic pipeline. The type of DVG most described for influenza infections (deletion DVGs) differs from the most commonly described DVGs from non-segmented negative stranded viruses (5' copyback). This could be attributed to either differences between viruses or the tools used to detect and characterize DVGs. Here we analyze several NGS datasets from people infected with different types of influenza virus using the same bioinformatic pipeline. We observe that 5' copyback DVGs are prevalent in all human clinical samples but not in the cultured samples. To address this discrepancy between clinical and laboratory cultures, we infected cell culture and ferrets with an H5N8 influenza A virus (FLUAV) and analyzed the DVG composition. The results demonstrate that the DVG population is skewed toward 5' copyback DVGs in the in vivo infections and deletion DVGs in the in vitro infections. This demonstrates that there are differences in vivo genome production and in vitro genome production, and this has implications for how the role of DVGs in clinical disease is studied. We also investigate the role the host cofactor ANP32B has in DVG production.

Removing Dust From the German Health Care System by Introducing Health Apps Into Standard Care: Semistructured Interview Study

BACKGROUND

In 2019, Germany launched the Digital Healthcare Act. The reform enables physicians to prescribe health apps as treatments to their statutory-insured patients.

OBJECTIVE

We aimed to determine the extent to which the integration of health apps into standard care could be considered beneficial and which aspects of the regulation could still be improved.

METHODS

We conducted a semistructured interview study with 23 stakeholders in Germany and analyzed them thematically. We used descriptive coding for the first-order codes and pattern coding for the second-order codes.

RESULTS

We created 79 first-order codes and 9 second-order codes following the interview study. Most stakeholders argued that the option of prescribing health apps could improve treatment quality.

CONCLUSIONS

The inclusion of health apps into German standard care could improve the quality of treatment by expanding treatment portfolios. The educational elements of the apps might additionally lead to more patient emancipation through a better understanding of personal conditions. Location and time flexibility are the biggest advantages of the new technologies, but they also raise the most significant concerns for stakeholders because app use requires personal initiative and self-motivation. Overall, stakeholders agree that the Digital Healthcare Act has the potential to remove dust from the German health care system.

[Digital health applications: statutory introduction of patient-centred digital innovations into healthcare]

The Digital Healthcare Act (DVG) and the Digital Health Applications Ordinance (DiGAV) defined digital health applications (DiGA) and included these as an entitlement of statutory health insurance (GKV). Further development of this new area of healthcare occurred within the Digital Healthcare and Care Modernization Act (DVPMG). Every doctor and psychotherapist can prescribe digital applications at the expense of statutory health insurance funding, provided the applications have successfully undergone a three-month test procedure at the Federal Institute for Drugs and Medical Devices (BfArM) and are listed in their DiGA directory. Provisional admissions of DiGA accompanied by scientific studies and evaluations are also possible.The legislator has thus actively incorporated the highly dynamic technological and social development of digital innovations into healthcare by introducing mobile applications for therapeutic purposes. The legal framework is designed in such a way that DiGA can not only potentially support aspects of patient-centred care, such as strengthening of self-management, health literacy and adherence but also optimize treatment procedures and interaction between patients and service providers in many ways.Extensive specifications for technical interoperability between DiGA and other types of medical devices and implants, as well as the electronic patient record (ePA), will accelerate the integration of DiGA into day-to-day care. Overall, it is of utmost importance to incorporate DiGA into existing care as enriching, user-friendly and digitally supported processes. Hence, the initial regulatory framework will continuously be adapted and developed in the years to come - shaped by the experiences gained with innovative products and the administrative procedures used to admit them.

[Digital health applications (DiGA): assessment of reimbursability by means of the "DiGA Fast Track" procedure at the Federal Institute for Drugs and Medical Devices (BfArM)]

Mit dem Digitale-Versorgung-Gesetz (DVG) hat der Gesetzgeber digitalen Gesundheitsanwendungen, kurz DiGA, einen Einzug in die Regelversorgung nach dem Fünften Buch Sozialgesetzbuch (SGB V) ermöglicht. Voraussetzung für die „App auf Rezept“ ist die Listung im DiGA-Verzeichnis nach positiv durchlaufenem Bewertungsverfahren beim Bundesinstitut für Arzneimittel und Medizinprodukte (BfArM). Dafür ist von den Herstellern neben umfangreichen Qualitäts- und Sicherheitsparametern auch ein positiver Versorgungseffekt nachzuweisen.

Mit dem DiGA-Verzeichnis bietet das BfArM seit Oktober 2020 adressatengerechte umfassende Transparenz zu den DiGA und deren Eigenschaften. Der Artikel erläutert den Weg zur „App auf Rezept“ von den Unterstützungs- und Beratungsangeboten durch das BfArM über den Ablauf des Bewertungsverfahrens (DiGA-Fast-Track) und die Bewertungskriterien bis hin zu den Inhalten des Verzeichnisses. Es zeigt sich, dass das Interesse an dem Fast-Track-Verfahren groß ist. Der Nachweis der positiven Versorgungseffekte, also eines tatsächlichen Mehrwerts für die Patienten, ist ausbalanciert und mit überwiegend randomisierten kontrollierten Studiennachweisen auf einem angemessenen Niveau. Dass das Verfahren auch mit Herausforderungen für die Antragsteller verbunden sein kann, z. B. Mängel adäquat in dem gesetzlich vorgegebenen Bewertungszeitraum zu adressieren, zeigen die Zahlen zurückgenommener Anträge im Verhältnis zu den gelisteten DiGA an. Das BfArM steht zu diesem neuen Verfahren in engem Austausch mit allen Beteiligten. Welche Überlegungen und Potenziale sich daraus für die Weiterentwicklung aus Sicht des BfArM ergeben, zeigt der Ausblick.

The influenza virus RNA polymerase as an innate immune agonist and antagonist

Influenza A viruses cause a mild-to-severe respiratory disease that affects millions of people each year. One of the many determinants of disease outcome is the innate immune response to the viral infection. While antiviral responses are essential for viral clearance, excessive innate immune activation promotes lung damage and disease. The influenza A virus RNA polymerase is one of viral proteins that affect innate immune activation during infection, but the mechanisms behind this activity are not well understood. In this review, we discuss how the viral RNA polymerase can both activate and suppress innate immune responses by either producing immunostimulatory RNA species or directly targeting the components of the innate immune signalling pathway, respectively. Furthermore, we provide a comprehensive overview of the polymerase residues, and their mutations, associated with changes in innate immune activation, and discuss their putative effects on polymerase function based on recent advances in our understanding of the influenza A virus RNA polymerase structure.

Highly immunostimulatory RNA derived from a Sendai virus defective viral genome

Defective viral genomes (DVGs) are generated during virus replication. DVGs bearing complementary ends are strong inducers of dendritic cell (DC) maturation and of the expression of antiviral and pro-inflammatory cytokines by triggering signaling of the RIG-I family of intracellular pattern recognition receptors. Our data show that DCs stimulated with virus containing DVGs have an enhanced ability to activate human T cells and can induce adaptive immunity in mice. In addition, we describe the generation of a short Sendai virus (SeV)-derived DVG RNA (DVG-324) that maintains strong immunostimulatory activity in vitro and in vivo. DVG-324 induced high levels of Ifnb expression when transfected into cells and triggered fast expression of pro-inflammatory cytokines and mobilization of dendritic cells when injected into the footpad of mice. Importantly, DVG-324 enhanced the production of antibodies to a prototypic vaccine after a single intramuscular immunization in mice. Notably, the pro-inflammatory cytokine profile induced by DVG-324 was different from that induced by poly I:C, the only viral RNA analog currently used as an immunostimulant in vivo, suggesting a distinct mechanism of action. SeV-derived oligonucleotides represent novel alternatives to be harnessed as potent adjuvants for vaccination.