Bacteremic pneumococcal pneumonia in one American City: a 20-year longitudinal study, 1978-1997.

A surveillance of bacteremic pneumococcal pneumonia was conducted in Huntington, West Virginia, from 1978 to 1997 to investigate case-fatality rates, incidence of disease, capsular types, and antibiotic usage. Our study population comprised consecutive inpatients admitted to the hospitals in Huntington, West Virginia, and included 45 children younger than 15 years and 328 adults. All blood isolates were serotyped by capsular swelling procedures; clinical characteristics, treatment, and outcome for all patients were abstracted from hospital charts. The overall case-fatality rate was 20.3%, with most deaths occurring among adults older than 50 years. Case-fatality rates peaked at 37.7% among patients 80 years of age and older. Only 1 of 45 (2.2%) children died. Case-fatality rates declined in each successive 5-year period, from 30.2% in 1978-1982 to 15.6% in 1993-1997. In that same period, incidence rates increased severalfold among children younger than 4 years to 44.5 cases per 100,000 population and among adults 70 years and 80 years of age and older to 38.5 and 76.2 cases per 100,000, respectively. Of the 34 serotypes isolated, 10 accounted for two thirds of the cases of pneumonia: 1, 4, 9, 14, 3, 6, 12, 5, 23, and 19 (in rank order). Chronic renal disease and arteriosclerotic heart disease increased the risk of death. Treatment regimens that included a macrolide and a penicillin or cephalosporin resulted in the lowest case-fatality rate in adults older than 50 years: 6% in 1993-1997. In conclusion, as bacteremic pneumococcal pneumonia evolved over time, the case-fatality rate decreased, its incidence increased, predominant capsular types changed, and treatment regimens that included a macrolide resulted in the lowest fatality rates.

Deaths in bacteremic pneumococcal pneumonia. A comparison of two populations--Huntington, WVa, and Stockholm, Sweden.

The case fatality rate in bacteremic pneumococcal pneumonia (Pnb) has been reported to be lower in Sweden than in the United States. We retrospectively compared 231 adult Pnb patients in Stockholm (STO), Sweden, with 107 patients infected with the same serotypes or groups in Huntington, WVa (HWV). The total case fatality rate was 11/231 (5 percent) in STO versus 28/107 (26 percent) in HWV (p < 0.001), being significantly lower in STO for all age groups. Patients from HWV more often had preexisting chronic diseases, while alcoholism was more prevalent in STO. The case fatality rate was similar among alcoholics in STO and HWV, while it was much higher in nonalcoholic patients with chronic diseases in HWV (22/73;30 percent) than in STO (2/88;2 percent) (p < 0.001). No bias was found that could account for more than a small part of the higher case fatality rate in HWV. Thus, underlying chronic diseases in HWV accounted for some of the increased risk of death in this patient group. However, the major part of the difference in death rates between HWV and STO remains unexplained.

Occurrence, characteristics, and patterns of HIV-1 and HIV-2 western blot indeterminate sera in low risk populations in West Virginia and pre-AIDS Africa.

To further characterize HIV-1 and HIV-2 Western blot indeterminate (IWB) sera, 402 sera from 318 healthy low-risk individuals from West Virginia and 159 African sera obtained in the pre-AIDS era (1968-1972) were studied. All IWB sera tested for antigen by HIV-1 enzyme immunoassay (EIA-Ag) were negative. HIV-1 and HIV-2 IWB reactivity occurred independent of HIV-1 and HIV-2 false-positive testing for antibody by enzyme immunoassay (EIA-Ab) and no cross-reactions between HIV-1 and HIV-2 IWB patterns were detected. The IWB patterns were reproducible, demonstrated no age or sex related pattern, and showed no evidence of vertical or horizontal transmission. The African sera exhibited a significantly higher number of IWB patterns. IWB reactivity in HIV-1 and HIV-2 seronegative individuals may not be viral in origin and the occurrence of IWB pattern may vary among populations.

Detection of antigen in immune precipitates by silver staining of SDS-polyacrylamide gels.

The silver staining technique of Merril et al. (1981) was used to identify antigens separated by SDS-PAGE after dissociation of immune complexes purified by absorption with staphylococcus A protein. The five and four dominating structural components of measles and RS virus (Mr range 28,000 to 79,000) respectively precipitated with monoclonal antibodies were readily identified, except when the Mr of the virus-specific antigen was in the same range as immunoglobulin heavy and light chains. Specific antigens were identified less effectively after precipitation with polyclonal sera because of a larger background of stainable proteins. This method, which combines the sensitivity and high resolution of silver staining and the specificity of immune complexing with monoclonal antibodies, is rapid and inexpensive.

Antibody response of pneumococcal vaccine: need for booster dosing?

The approved pneumococcal vaccine comprises purified capsular polysaccharide of 23 stereotypes that account for more than 90% of the invasive pneumococcal infections in the USA. It induces adequate anti-polysaccharide IgG antibody levels to most or all of the component polysaccharide antigens in immunocompetent adults. Elderly adults respond about equally well to vaccination as do younger adults. Pneumococcal antibody declines over time, often below 1 month post-vaccination levels, and sometimes about to pre-primary vaccination levels. Second doses of vaccine satisfactorily boost antibody levels in healthy adults, but not in immunocompromised adults or children. The rate of antibody decline differs for the differing capsular stereotypes. In time, pneumococcal antibody wanes in all healthy persons perhaps increasing their risk of serious pneumococcal disease. Elderly and high risk persons face the highest risk of death from invasive pneumococcal disease, supporting the proposition that for these groups revaccination with pneumococcal vaccine at regular intervals may provide the needed increased measure of protection.

Production and characterization of monoclonal antibodies to bovine respiratory syncytial virus.

Monoclonal antibodies to the SmithKline Beecham Animal Health BRSVR vaccine strain (375 isolate of Bovine Respiratory Syncytial Virus) were produced and then characterized by radioimmunoprecipitation followed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, virus neutralization, inhibition of viral-induced fusion and isotype. Nineteen hybridomas produced antibodies that were reactive with the F0, F1, N or P viral proteins of bovine respiratory syncytial virus. One hybridoma (1E72C4) produced antibodies that immunoprecipitated the F0 glycoprotein, neutralized virus (1:8) in the presence of complement, but did not inhibit fusion. Another hybridoma (8B21E7) produced antibodies that immunoprecipitated the F0, F1 and F2 glycoproteins, neutralized virus (1:4) with and without complement and inhibited fusion. Antibodies from 11 hybridomas immunoprecipitated N and F1 proteins, one hybridoma immunoprecipitated the N and P protein, and 5 hybridomas immunoprecipitated the N protein. All monoclonal antibodies were of the IgG2b subtype with either kappa or lambda light chains.

Emergence of penicillin-resistant invasive pneumococci in a single American community.

Three decades ago, penicillin-resistant strains of Streptococcus pneumoniae were first reported. Since then, myriad penicillin resistant strains of S. pneumoniae have been identified worldwide and in the United States. No resistant or intermediate resistant strains have been reported in West Virginia because testing has not been done. Between 1983 and 1994, the authors' surveillance of invasive pneumococcal disease in metropolitan Huntington, West Virginia, identified 356 pneumococcal strains from blood and other usually sterile sites, including 110 strains belonging to serotypes 6, 9, 14, 19, and 23, the main serotypes exhibiting penicillin resistance. The authors tested these serotypes for penicillin susceptibility by the E-test. Sixteen (14.5%) strains of types 6, 9, 14, 19, and 23 exhibited intermediate resistance to penicillin. No highly resistant strains were identified. Most of the intermediate resistant strains of types 9, 14, and 23 were detected in epidemiologic years 1992-1994. The increasing number of intermediate resistant penicillin strains signals the need for routine testing of invasive pneumococcal strains for penicillin susceptibility and necessitates appropriate antibiotic usage.

Pneumococcal antibody levels one decade after immunization of healthy adults.

The authors investigated the persistence of anticapsular pneumococcal antibodies in 21 subjects one decade after administration of a single dose of a polyvalent pneumococcal polysaccharide vaccine. Fourteen vaccinees received a hexavalent vaccine composed of the polysaccharides of capsular types 1, 3, 4, 7F, 8, and 12F; four vaccinees received an octavalent vaccine consisting of these six polysaccharides and also those of capsular types 14 and 19F; and three vaccinees received a nonavalent vaccine that also included type 5 capsular polysaccharide. Antibody was measured by radioimmunoassay. The authors detected persistently elevated anticapsular antibody levels among more than one half of vaccinees who developed a significant rise in antibody 1 month following immunization one decade after administration of pneumococcal polysaccharide vaccine when these levels were compared to prevaccine levels for pneumococcal capsular types 4, 7F, and 8. This finding was not the case with pneumococcal types 1, 3, 12F, 14, and 19F; less than two fifths of vaccinees maintained increased levels of anticapsular antibody to these types one decade after administration of pneumococcal vaccine. Geometric mean anticapsular antibody levels for types 7F and 8 only were significantly higher one decade after vaccine administration compared with the levels before immunization (t-test, p less than 0.01).

Phosphoprotein profile analysis of ruminant respiratory syncytial virus isolates.

OBJECTIVE: To determine the apparent molecular weight for 24 ruminant respiratory syncytial viruses (RSV) on the basis of differences in the electrophoretic mobility of the phosphoprotein (P protein). PROCEDURE: 29 bovine RSV (BRSV), 20 of which were not previously tested, 3 ovine RSV, and 1 caprine RSV isolates were selected for determination of electrophoretic mobility of the P protein. Virus radiolabeled with [35S]methionine was immunoprecipitated with polyclonal antiserum to BRSV and analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. RESULTS: On the basis of apparent molecular size of the P protein, all isolates could be categorized into 2 electropherotypes, low molecular size of 36 kd and high molecular size of 38 kd. Twenty-three BRSV, the 3 ovine RSV, and 1 caprine RSV isolates had a high molecular size P protein; 6 BRSV isolates had a low molecular size P protein. CONCLUSIONS: The apparent molecular size of the P protein of the ruminant RSV strains is greater than that of the human RSV subgroups, providing further evidence of their distinctiveness. Whether categorization of electrophoretic mobility of the P protein of BRSV underlies distinct antigenic subgroups, as it does in human RSV, requires further antigenic and genetic analysis. CLINICAL RELEVANCE: Antigenic subgroups of ruminant RSV may have relevance in the development of new vaccines for control of the disease.

Characteristics and outcome variables of HIV cases at a university-based medical practice.

An increasing number of AIDS cases occur each year in West Virginia despite its small urban population. From January 1984 to March 1991 at the Marshall University based multispecialty internal medicine group (the University Physicians in Internal Medicine), 66 HIV-infected persons were treated, most of whom are native West Virginians and always resided in the state. The study group consisted of 61 men and 5 women; four-fifths of the men are homosexual/bisexual and one-seventh used intravenous illicit drugs. Four women acquired infection heterosexually and one from transfusion. Twenty-eight patients never had any opportunistic infection (OI) and 38 experienced at least one OI, usually Pneumocystis carinii Pneumonia. About two-fifths of patients had CD4 counts less than 200 cells/cmm at their initial examination. Three-fourths of patients received AZT, six ddI, and most aerosolized pentamidine. Nineteen patients have died, all of whom suffered at least one OI. The mean interval until death from HIV infection and from AIDS was about 27 and 11.5 months, respectively.