Rotary International: a partner in polio eradication.

Rotary International remains committed to the goal of global eradication of polio and certification by 2005. The reports of possible sources of virulent vaccine-derived poliovirus, which may persist after the global eradication of wild poliovirus, need to be investigated rapidly. If these sources are confirmed to be significant risks to global polio eradication, methods to eliminate these sources need to be identified and implemented. Final recommendations on the stopping of vaccination need to be made by WHO.

Association between HIV in pregnancy and antiretroviral therapy, including protease inhibitors and low birth weight infants.

OBJECTIVE: To determine the incidence of low birth weight infants born to HIV seropositive women and to demonstrate any effects of antiretroviral therapy on birth weight. METHODS: Retrospective review of all obstetrical medical records from January 1, 1995 through June 30, 1998 to identify HIV seropositive women. We evaluated their antiretroviral therapy, CD4 counts, and birth weights of their newborns. We conducted detailed review of the clinical and laboratory findings for the HIV-infected untreated patients, women who received ZDV antepartum alone, and those who received PIs as part of antiretroviral treatment. RESULTS: The frequency of low birth weight infants was significantly increased in HIV seropositive compared to HIV seronegative parturients. Low birth weight infants were more frequent among HIV infected women with lower CD4 counts but the association was not statistically significant. Women who received no antepartum treatment, antepartum only ZDV, and those treated with PIs had significantly more low birth weight infants than did comparison groups. HIV seropositive women also had high frequencies of several obstetrical risk factors for low birth weight infants. CONCLUSION: The present study showed a significantly increased frequency of low birth weight infants among HIV infected women and especially the subgroups of infected women who received no antepartum treatment, antepartum ZDV only, and those treated with PIs. This association, however, may be related to the presence of many other preterm obstetrical risk factors noted in this study. Increasing numbers of HIV seropositive women are being treated with PIs according to the Centers for Disease Control (CDC) guidelines. If PIs are a cause of low birth weight infants, women taking these drugs may have incremental risk of low birth weight.

Epstein-Barr virus DNA in the blood of infants, young children, and adults by age and HIV status.

Polymerase chain reaction (PCR) methodology was used to detect Epstein-Barr virus (EBV) DNA in peripheral blood mononuclear cells (PBMCs) from children and adults whose HIV status (i.e., infected or uninfected) is known. Initial EBV infections especially occurred in children between the ages of 7 and 24 months. EBV-positive children with vertically acquired HIV infection tended to have a detectable blood level of EBV DNA for a period of years, and their EBV DNA blood levels often exceeded 10,000 copies/0.1 ml of blood--hundreds of times higher than levels typically found in EBV-positive, HIV-uninfected children of the same age. EBV DNA was found in PBMCs in 26% of 49 HIV-infected mothers who were sampled during their pregnancy, but the median EBV DNA level in their EBV-positive samples was low--only 50 copies/0.1 ml blood. In limited tests with specimens from children infected with both HIV and EBV, high blood levels of EBV DNA unexpectedly appeared to be associated with decreased blood levels of HIV DNA (p = .063).

HIV DNA blood levels in vertically infected pediatric patients: variations with age, association with disease progression, and comparison with blood levels in infected mothers.

Blood levels of HIV DNA in our vertically infected pediatric patients typically followed a characteristic age-related pattern: continuously increasing with increasing age to a peak between ages 4 and 8 months, and thereafter rather steadily declining. Median HIV DNA levels peaked about 3 months earlier in children who by age 24 months developed more severe rather than less severe HIV disease. Children at particular risk of developing severe HIV disease by age 24 months commonly had > 800 HIV DNA copies per 0.1 ml of blood at age 3 weeks to 2 months, > 1,000 copies at 2 to 4 months, and > 2,500 copies at ages 4 to 6 months. Near the time of delivery mothers who transmitted HIV had significantly higher median blood levels of HIV DNA than mothers who did not transmit, but median HIV DNA levels in infected mothers as a group were low compared with those in pediatric patients > or = 1 month of age.

Viral studies of mothers with human immunodeficiency virus infection at delivery and their infants in the first 3 days of life.

OBJECTIVE: We studied 49 mother-infant pairs for human immunodeficiency virus (HIV) (a) to assess the virological and immunological status of HIV-infected mothers at delivery and their infants within the first 3 days of the infant's life, and (b) to correlate these findings with eventual infection outcome in the infant. METHOD: Maternal blood from women in labor and infant's blood within 3 days of life were tested for the titer of HIV immunoglobulin G (IgG) antibody, for presence of HIV by culture, for p24 antigen, for HIV DNA by polymerase chain reaction (PCR), and for absolute T-helper cell count (CD4). RESULTS: Eight infants were in the confirmed infected (CI) group, with a transmission rate of 21%. Thirty infants were in the confirmed uninfected (CU) group. In the mother, mean anti-HIV IgG titer was 1:2600 (CI group) and 1:3350 (CU group); in the infant, the mean titer was 1:3250 (CI group) and 1:2710 (CU group). Eighty-seven percent of the mothers were culture-positive in the CI group compared to 33% in the CU group (p = 0.005). Eighty-seven percent of CI infants were PCR-positive at birth; none was PCR-positive in the CU group (sensitivity = 87%; specificity = 100%). Sixty-two percent of CI infants were culture-positive at birth, whereas none was positive in the CU group (sensitivity = 62%; specificity = 100%). Of the uninfected infants, 23% were positive for p24 antigen at birth. CONCLUSIONS: HIV IgG antibody titers in mothers and their infants at birth were markedly elevated in both CI and CU groups but were not protective against infection. However, the high titers explain the long duration of this antibody in the blood of infants born to infected mothers. Culture positivity in the mother at delivery correlated highly with eventual infection in the infant (p = 0.005). HIV antigen, specifically p24 antigen, was detectable in uninfected infants when tested at birth.

HIV antibody responses in children of HIV-infected mothers.

About 25% of the children of untreated HIV-infected mothers are later determined to be HIV-infected. At birth, all of the children of HIV-infected mothers have HIV-IgG antibody, which is transferred transplacentally from the mothers to their children, and infected children produce HIV-IgG antibody in response to their infection. Most infected children have detectable HIV-IgA by 3 months of age. We have studied HIV antibody responses in three groups of children of HIV-infected mothers at 9 to 12 months and 15 to 24 months of age. The groups were classified by Centers for Disease Control and Prevention (CDC) criteria and included: (I) HIV seroreverters (SR); (II) HIV-infected; Non- to mildly symptomatic (N+A); and (III) HIV-infected; Moderately to Severely Symptomatic (B+C). HIV-IgG antibody was detected in some SR children at low titer levels (10 to 20) through 11 months of age but not at 12 or later. For both the N+A and B+C groups, there were no significant changes in the mean HIV-IgG titers from 9-12 to 15-24 months of age. Also, no significant difference in titers were found between the two infected groups for both age groups. HIV-IgA antibody responses were more frequently positive at 15 to 24 months for all seven antigens studied for the N+A than the B+C patients; however, statistical significance was attained only for gp41 (p < or = 0.01). N+A children showed more responses to the viral antigens at 15-24 months than at 9-12 months. This increase in HIV-specific IgA among the N+A children may be important in restricting their HIV infections. Total IgG levels were significantly higher in the HIV-infected groups than in the SR (p < or = 0.0001), but no differences were detected between the N+A and B+C groups. Total IgA increased over time in the N+A patients from 9-12 to 15-24 months. A similar trend was apparent in the B+C group, but did not reach statistical significance. Both N+A and B+C patients at 15-24 months had significantly higher total IgA levels than did the SR at 9-12 months of age. The B+C group had significantly lower CD4 counts for both age groups than did the N+A or SR groups (p < or = 0.0001).

Coinfection with herpesviruses in young children of HIV-infected women.

Coinfection with herpesviruses in young children born to human immunodeficiency virus (HIV)-infected women was studied with blood samples from children who were 9-12 months and 15-24 months of age. Three groups of children were included: (I) HIV-uninfected, asymptomatic (HIV-); (II) polymerase chain reaction (PCR) and/or culture-positive and asymptomatic or mildly symptomatic (HIV+ asymptomatic); and (III) PCR and/or culture-positive and symptomatic (HIV+ symptomatic). Significantly more of the HIV+ symptomatic patients had cytomegalovirus (CMV) antibody than the HIV patients. In addition, CMV antibody levels were significantly higher in the HIV+ symptomatic patients than in either of the other two groups. Human herpesvirus 7 (HHV-7) antibody titers were significantly different among the three groups of patients; however, no pairwise comparisons were significant. No differences were found for HHV-6 or Epstein-Barr virus (EBV) antibody frequencies or titers. These findings suggest that infection with CMV is a cofactor or an opportunistic infection causing symptomatic HIV infections in young children.

In utero diagnosis of congenital infections by direct fetal sampling.

Counseling for infections during pregnancy has traditionally focused on the clinical and laboratory findings of infection in the mother and the estimated risk of fetal damage associated with possible transmission of infection to the child. Now, with the use of techniques for fetal sampling, it is possible to diagnose infections of the fetus in utero and to correlate that information with the occurrence of fetal damage. The techniques that are available for sampling include amniocentesis, cordocentesis and chorionic villus sampling. The laboratory tests include: a) isolation of the organism in appropriate laboratory systems; b) detection of the DNA or RNA of the organism directly or with amplification with techniques such as PCR; c) detection of the organism by fluorescence or in situ hybridization; and d) identification of IgM or IgA fetal antibody to the organism by ELISA or similar methods. In utero infections can be documented for agents such as rubella, cytomegalovirus, parvovirus, Toxoplasma gondii and human immunodeficiency virus type 1. Further information is needed concerning the sensitivities and specificities of these methods for identifying fetal infection and predicting fetal damage.

Early diagnosis and immunologic changes in HIV-1 infected pregnant women and their children.

The diagnosis of HIV infection in pregnant women is usually based on the detection of HIV-specific antibodies. These tests become positive a few weeks to months after infection. In the United States, it is recommended that tests be offered to all women and encouraged where the rate of infection is > or = 1/1,000 or the woman is at increased risk for infection. The great majority of infected pregnant women are asymptomatic, and questioning patients about risk behavior will identify only about one-half of the infected women. In Washington, D.C. about 1.5% of the pregnant women who reside in the city are HIV positive. The diagnosis of HIV in the child in the first month of life is difficult and requires the use of polymerase chain reaction tests and/or culture. Other tests become positive later. Immunological tests in most HIV-infected mothers in the USA are normal; however, about 12% of patients are symptomatic and show decreased CD4 T cell counts and 6% have AIDS. These patients may have other evidence of decreased T cell responses and are at increased risk for opportunistic infections. At birth, almost all children of HIV-infected mothers have normal immunological findings. However, about 50 of these children become ill by 1 year of age and many develop decreased T cell counts and other immunological changes.

Human immunodeficiency virus infection in infants during the first 2 months of life. Reliable detection and evidence of in utero transmission.

OBJECTIVE: To evaluate the clinical utility of a polymerase chain reaction (PCR) method for detecting human immunodeficiency virus (HIV) infection in infants 2 months of age or younger who were born to HIV-positive mothers. DESIGN: Prospective, longitudinal study lasting 3 years. The PCR tests were performed with coded peripheral blood mononuclear cell lysates, and results were compared with findings using Centers for Disease Control and Prevention (CDC) (Atlanta, Ga) criteria defining HIV infection in children. SETTING: Hospitals, particularly a pediatric hospital in Washington, DC. PATIENTS: Newborns, young infants, and HIV-infected mothers. OUTCOME MEASURE: Presence or absence of pediatric HIV infection using CDC criteria compared with a diagnosis based on the detected presence or absence of HIV proviral DNA using PCR testing. RESULTS: One or more blood samples obtained by 62 days of age from 30 (94%) of 32 HIV-infected infants were positive for HIV by routine PCR testing. Blood samples from 32 infants now confirmed to be uninfected tested negative for HIV. Human immunodeficiency virus DNA was detected in blood samples obtained within 48 hours of birth from eight of nine infected infants. In six of these newborns as well as most older infants, HIV DNA was present in such quantity that it was detectable in specimens equivalent to 0.01 mL or less of the original blood sample. CONCLUSIONS: Our PCR procedure can reliably detect the presence or absence of HIV infection during the first 2 months of life. The frequent presence and not uncommon high titer of HIV DNA within 48 hours of birth suggest that much of the transmission of HIV from mother to infant occurs well before birth.

Fetal damage caused by parvoviral infections.

The single-stranded DNA parvoviruses occur in humans and many species of animals. In general, they are species-specific and capable of producing disease at any stage of life. Parvoviruses have a requirement to replicate in cells in a permissive S-phase of DNA mitosis. The infections may be cytolytic to select cell groups resulting in specific developmental defects or may produce more generalized effects such as anemia, pancytopenia, or hemorrhage. The fetus is at particular risk for damage because of the vast number of cells in active mitosis. The teratogenic effects may be severe, often resulting in fetal death. Infections in childhood and adulthood are more frequently mild to subclinical. Some of the teratogenic effects recognized in animal species have been identified in humans. With increased knowledge of parvovirus effects in animals, more pathogenic effects may be related to human parvoviral disease. The need for vaccination, currently used annually in many domestic animal species, continues to be evaluated for humans.

Cellular immune factors associated with mother-to-infant transmission of HIV.

OBJECTIVE: To study a possible correlate of protection in mother-to-infant transmission of HIV infection. In particular, to determine whether lack of HIV-specific T-helper (TH) function as indicated by HIV and non-HIV antigen-stimulated interleukin (IL)-2 production of mother and/or newborn peripheral blood leukocytes (PBL) is associated with mother-to-infant transmission of HIV. METHODS: PBL from 21 HIV-seropositive pregnant women and 23 cord blood leukocytes (CBL) from their offspring were studied for in vitro TH function by IL-2 production in response to HIV and non-HIV antigens. Polymerase chain reaction (PCR) and viral culture assays were performed to determine HIV infection of the infants. RESULTS: PBL from 10 out of 21 (48%) mothers and from eight out of 23 (35%) CBL samples responded to two or more out of five synthetic gp 160 envelope (env) peptides. Three of the 23 (13%) offspring were shown to be HIV-infected by PCR and/or viral culture on follow-up. All three infected infants were from a subset whose CBL did not exhibit env-specific TH immunity. CONCLUSION: Our results demonstrate that fetal T cells can be primed to HIV env determinants in utero, suggest that HIV-specific TH immunity may be protective in newborns, and provide a possible means for identifying newborns who are at risk for HIV infection.

Perinatal 'TORCH' infections identified by serology: correlation with abnormalities in the children through 7 years of age.

A matched case-control methodology was used to assess the risk for a wide range of abnormalities in children associated with serological evidence for 'TORCH' infections in the mothers. Specimens were selected from the large bank of sera from the approximately 54,000 pregnant women who participated in the Collaborative Perinatal Project. There was no clear association between any of the antigens studied and any specific damage to the child. These 'negative' findings are consistent with the absence of frequent significant effects due to these agents in the second and third trimesters of pregnancy.

"PolioPlus", a booster shot.

PIP: In 1979, Rotary International, a US-based voluntary service organization, began its immunization efforts in collaboration with WHO and other groups. That year it and a private Canadian donor sent 4 tons of polio vaccines and 683,000 doses of tetanus toxoid to the Philippines. A large-scale measles immunization project in southern India proposed by Canadian and Indian Rotarians in 1980 received grants from Rotary International and the Canadian International Development Agency to immunize 3 million children. In 1982, it expanded its goal to immunization of all children in the world by 2005. By 1985, it formed its Polio Plus Program. Polio Plus provides grants to ministries of health after assuring that the ministries have a WHO-approved plan for immunization and agree to not hold Rotary International accountable for any problems and that local Rotarians support the project. By mid-1990, most grants had gone to southeast Asia (31%), sub-Saharan Africa (23%), and Latin America (22%). In early 1989, Rotary International had purchased 80% of the polio vaccine issued by PAHO and UNICEF. Local Rotarians along with colleagues from other countries organize social mobilization efforts. They also receive training manuals and undergo practical training via international voluntary exchanges. The manuals discuss vaccine promotion, organizing a delivery system, and training teams to help with immunization and monitor outcomes. Various ways Rotarians publicize programs are posters, banners, children's demonstrations, and radio and TV spots. They also provide refrigerated vehicles, participate in censuses, and sponsor workshops for health professionals. In late 1988, it gave PAHO and WHO grants to improve immunization efforts. By mid-1990, Rotary International fund-raising efforts had generated US$ 210 million with an additional US$ 20 million promised. It has invested these funds.^ieng

Detection of human immunodeficiency virus type 1 infection in young pediatric patients by using polymerase chain reaction and biotinylated probes.

Polymerase chain reaction (PCR) testing using up to four primer pairs and biotinylated probes was 97.9% sensitive (188 of 192 specimens positive) and 100% specific (267 of 267 specimens negative) for detecting the presence or absence of human immunodeficiency virus (HIV) DNA in peripheral blood mononuclear cells from pediatric patients whose HIV status has been confirmed. SK38/39 and SK145/150 were the most sensitive primer pairs, respectively detecting HIV DNA in 95.6 and 95.9% of peripheral blood mononuclear cell specimens from HIV-infected children and collectively detecting all adequately tested PCR-positive specimens. Primer pairs SK29/30 and SK68/69 respectively detected HIV DNA in only 76.4 and 76.6% of HIV-positive specimens. Among infants born to HIV-seropositive mothers, 30 who subsequently were confirmed to be infected were sampled when they were less than or equal to 6 months of age; in all but one infant, HIV DNA was found in the first specimen collected. Among the nine youngest infected infants tested, all were PCR positive by 38 days of age. PCR methods thus have reliably detected vertically transmitted HIV infection early in life.

Limitations in the laboratory diagnosis of vertically acquired HIV infection.

At present, the only well-standardized and widely available diagnostic techniques for HIV infection are detection of IgG HIV antibodies and HIV antigen. The antibody detection is sensitive, but is useful only in infants and children older than 15 months because of the presence of maternal antibodies. The utility of HIV antigen testing in neonates and young infants has not been established. A number of sensitive techniques, such as PCR, ELISPOT, and detection of HIV-specific IgM and IgA antibodies, are under development and promise to be very useful in the early diagnosis of vertical HIV infection. However, we will be able to accurately establish the sensitivity or specificity of the individual tests only when we have results of large prospective studies. These studies should compare different diagnostic methods and correlate the results of tests performed sequentially in neonates and young infants with the natural history of their disease process and eventual clinical outcome.