US-wide equine strongylid egg count data demonstrate seasonal and regional trends.

Equine strongylid parasites are ubiquitous around the world and are main targets of parasite control programmes. In recent years, automated fecal egg counting systems based on image analysis have become available allowing for collection and analysis of large-scale egg count data. This study aimed to evaluate equine strongylid fecal egg count (FEC) data generated with an automated system over three years in the US with specific attention to seasonal and regional trends in egg count magnitude and sampling activity. Five US regions were defined; North East, South East, North Central, South Central and West. The data set included state, region and zip code for each FEC. The number of FECs falling in each of the following categories were recorded: (1) 0 eggs per gram (EPG), (2) 1 ⩽ 200 EPG, (3) 201 ⩽ 500 EPG and (4) >500 EPG. The data included 58 329 FECs. A fixed effects model was constructed fitting the number of samples analysed per month, year and region, and a mixed effects model was constructed to fit the number of FECs falling in each of the 4 egg count categories defined above. The overall proportion of horses responsible for 80% of the total FEC output was 18.1%, and this was consistent across years, months and all regions except West, where the proportion was closer to 12%. Statistical analyses showed significant seasonal trends and regional differences of sampling frequency and FEC category. The data demonstrated that veterinarians tended to follow a biphasic pattern when monitoring strongylid FECs in horses, regardless of location.

Rapid, automated quantification of Haemonchus contortus ova in sheep faecal samples.

Haemonchus contortus is one of the most pathogenic nematodes affecting small ruminants globally and is responsible for large economic losses in the sheep and goat industry. Anthelmintic resistance is rampant in this parasite and thus parasite control programs must account for drug efficacy on individual farms and, sometimes, whether H. contortus is the most prevalent trichostrongylid. Historically, coproculture has been the main way to determine the prevalence of H. contortus in faecal samples due to the inability to morphologically differentiate between trichostrongylid egg types, but this process requires a skilled technician and takes multiple days to complete. Fluoresceinated peanut agglutinin (PNA) has been shown to specifically bind H. contortus and thus differentiate eggs based on whether they fluoresce, but this method has not been widely adopted. The ParasightTM System (PS) fluorescently stains helminth eggs in order to identify and quantify them, and the H. contortus PNA staining method was therefore adapted to this platform using methodology requiring only 20 min to obtain results. In this study, 74 fecal samples were collected from sheep and analyzed for PNA-stained H. contortus, using both PS and manual fluorescence microscopy. The percentage of H. contortus was determined based on standard total strongylid counts with PS or brightfield microscopy. Additionally, 15 samples were processed for coproculture with larval identification, and analyzed with both manual and automated PNA methods. All methods were compared using the coefficient of determination (R2) and the Lin's concordance correlation coefficient (ρc). ParasightTM and manual PNA percent H. contortus results were highly correlated with R2 = 0.8436 and ρc = 0.9100 for all 74 fecal samples. Coproculture versus PS percent H. contortus were also highly correlated with R2 = 0.8245 and ρc = 0.8605. Overall, this system provides a rapid and convenient method for determining the percentage of H. contortus in sheep and goat fecal samples without requiring specialized training.

Effects of sample homogenizing on the performance of an automated strongylid egg counting system.

Fecal egg counts are essential monitoring tools in veterinary parasite control. In recent years, several groups have developed automated egg counting systems based on image analysis and deep learning algorithms. Work in our laboratory demonstrated that an automated system performed with significantly better precision than traditional egg counting techniques. However, while the counting process is no longer operator dependent, the pre-analytical homogenization steps still are. This study aimed at evaluating the influence of sample homogenization on diagnostic performance on an automated equine strongylid egg counting system. Samples were collected from 12 horses and assigned to three egg count categories (four samples per category): Low (0-500 eggs per gram (EPG)), Moderate (501-1000 EPG), and High (1001-2000 EPG). Within each category, all samples were divided into four portions and each was analyzed with the automated system using the following four homogenizing procedures using a homogenizing device supplied with the system: 1) pressing the plunger five times and pouring directly into the counting chamber, 2) pressing the plunger five times and shaking the bottle prior to pouring, 3) pressing the plunger ten times with direct pouring, and 4) pressing the plunger ten times with shaking the bottle before pouring. There were no differences in precision expressed as coefficient of variation between these four procedures but shaking of the bottle prior to pouring was significantly associated with higher counts (p = 0.0068). These results demonstrate that the homogenization process can affect the diagnostic performance of an automated egg counting system and suggest that more efforts should be invested in standardizing and optimizing homogenization procedures.

Development and performance of an automated fecal egg count system for small ruminant strongylids.

An automated equine fecal egg count test, known as the Parasight System, was modified for use with small ruminants. Modifications included the introduction of a short centrifugation step in a floatation medium, an adjustment in pre-test sample filtering, and training of an image analysis-based egg counting algorithm to recognize and enumerate trichostrongylid eggs. In preliminary assessments, the modified method produced trichostrongylid egg counts comparable to manual McMaster analyses of the same samples from both ovine and caprine sources. The coefficient of determination (R2) for the linear correlation between McMaster and automated counts from these samples was 0.958, and there were no significant differences when comparing counts using feces from either sheep or goats. More extensive comparison utilized ovine samples split into three groups based on trichostrongylid egg content: Low (201-500 EPG), Medium (501-1000 EPG) and High (1001 or greater EPG). Each group contained 5 samples, each of which was used to produce individual slurries that were counted 8 times each using both McMaster and the automated method. This, again, showed no difference in accuracy between the techniques, but revealed significantly higher precision, as assessed by coefficients of variation (CoV), for the automated method for determining egg counts in the Low and Medium groups. The CoV of the McMaster method was 2.2, 2.5 and 1.3 times greater than the automated in the Low, Medium and High groups, respectively. Overall, the automated egg counting system showed good linear agreement with trichostrongylid egg counts determined with the McMaster method, and demonstrated significantly better precision. This technology reduces operator error and the results presented here illustrate its utility for determination of small ruminant trichostrongylid fecal egg counts.

Diagnostic performance of McMaster, Wisconsin, and automated egg counting techniques for enumeration of equine strongyle eggs in fecal samples.

Fecal egg counts are the cornerstone of equine parasite control programs. Previous work led to the development of an automated, image-analysis-based parasite egg counting system. The system has been further developed to include an automated reagent dispenser unit and a custom camera (CC) unit that generates higher resolution images, as well as a particle shape analysis (PSA) algorithm and machine learning (ML) algorithm. The first aim of this study was to conduct a comprehensive comparison of method precision between the original smartphone (SP) unit with the PSA algorithm, CC/PSA, CC/ML, and the traditional McMaster (MM) and Wisconsin (MW) manual techniques. Additionally, a Bayesian analysis was performed to estimate and compare sensitivity and specificity of all five methods. Feces were collected from horses, screened with triplicate Mini-FLOTAC counts, and placed into five categories: negative (no eggs seen), > 0 - ≤ 200 eggs per gram (EPG), > 200 - ≤ 500 EPG, > 500 - ≤ 1000 EPG, and > 1000 EPG. Ten replicates per horse were analyzed for each technique. Technical variability for samples > 200 EPG was significantly higher for MM than CC/PSA and CC/ML (p <  0.0001). Biological variability for samples> 0 was numerically highest for CC/PSA, but with samples > 200 EPG, MM had a significantly lower CV than MW (p =  0.001), MW had a significantly lower CV than CC/PSA (p <  0.0001), CC/ML had a significantly lower CV than both MW and SP/PSA (p <  0.0001, p =  0.0003), and CC/PSA had a significantly lower CV than CC/SP (p =  0.0115). Sensitivity was> 98 % for all five methods with no significant differences. Specificity, however, was significantly the highest for CC/PSA, followed numerically by SP/PSA, MM, CC/ML, and finally MW. Overall, the automated counting system is a promising new development in equine parasitology. Continued refinement to the counting algorithms will help improve precision and specificity, while additional research in areas such as egg loss, analyst variability at the counting step, and accuracy will help create a complete picture of its impact as a new fecal egg count method.

Pixel by pixel: real-time observation and quantification of passive flotation speeds of three common equine endoparasite egg types.

The efficacy of anthelmintic treatments against populations of endoparasites infecting livestock throughout the world is decreasing. To mitigate this, the use of fecal egg counts is recommended to determine both the necessity, and to ensure the appropriate choice, of anthelmintic treatment. Traditionally, and in order to facilitate easier identification and/or enumeration, samples are analysed after separating eggs from other fecal particulates by exposing them to a solution with a density higher than that of the eggs, but lower than the remaining fecal contents. While many parasite egg flotation protocols exist, little is known about the characteristics of these eggs with respect to their movement through a flotation solution. In this study, we have demonstrated a novel method for the observation and quantification of microscopic (65-100 µm) objects as they experience unassisted flotation. This also represents, to our knowledge for the first time, that the flotation of parasite eggs has been observed and their movement characteristics quantified as they float through solution. Particle tracking and video analysis software were utilised to automatically detect and track the movement of individual eggs as they floated. Three 30 s videos and one 2 min video of each egg type were analysed. If the first 30 s of video were discounted, the differences in mean flotation speed among all videos was statistically significant between egg types (P = 0.0004). Strongyle type eggs (n = 201) moved the fastest with a mean 51.08 µm/s (95% confidence interval: 47.54-54.62). This was followed by Parascaris spp. (n = 131) and Anoplocephala perfoliata eggs (n = 322), with mean speeds of 44.43 µm/s (95% confidence interval: 39.47-49.4) and 31.11 µm/s (95% confidence interval: 29.6-32.61), respectively. This method for evaluating the mean speed of passive flotation may represent a first step towards further optimizing fecal egg flotation and be of interest to parasitologists and veterinary practitioners.

The effect of counting duration on quantitative fecal egg count test performance.

Fecal egg counts are the primary diagnostic tools of equine parasitology and use of the McMaster test and its variants in clinical practice is widely recommended. Manual counting is, however, prone to various sources of human error. For example, in real-world situations analysts can be under significant pressure to process high numbers of samples in a limited time. This practice could affect test result quality, but yet no studies have determined whether this is the case. This study's purpose was to assess the effect of shortened counting duration (from either restricting counting time or counting only one grid of a slide) on McMaster test performance, and to compare the results to those of an automated test whose output is not subject to such limitations. Fifteen fecal samples from horses infected with strongylid parasites were divided equally into three groups based on high, medium and low levels of egg content (201-500, 501-1000 and 1001+ eggs/g). Slurries were produced from each sample and 10 subsamples of each were counted by both the McMaster and automated methods. McMaster slides were first counted at leisure, and then twice again with counting time being restricted to either one or two min. The effect of reducing sample processing time by counting only one grid of the McMaster slide was also assessed. Counting for one min significantly decreased manual egg counts by 50-60% relative to counts conducted at leisure (p < 0.001). While these decreases were somewhat ameliorated by counting for two min, the results were still approximately 10% lower than the at-leisure counts, a difference that was also statistically significant (p < 0.001). Furthermore, restricted counting duration also resulted in a significant decrease of approximately one-third in McMaster test precision, as assessed by the coefficients of variation (CoVs) of the 10 replicates of each sample, as did counting just a single grid of the McMaster slide. These differences effectively further improved the observed superior precision of the automated method compared to at-leisure manual McMaster counting, and the automated counts and their precision remained relatively unaffected following multiple analyses of the same processed samples. Taken together, these results indicate that analysists should carefully assess the possible effects on test performance of modifications to standard egg-counting procedures that are designed to account for real-world pressures, in order to achieve an optimal compromise between test accuracy and precision on one hand and practicality on the other.

The effect of counting duration on quantitative fecal egg count test performance.

Fecal egg counts are the primary diagnostic tools of equine parasitology and use of the McMaster test and its variants in clinical practice is widely recommended. Manual counting is, however, prone to various sources of human error. For example, in real-world situations analysts can be under significant pressure to process high numbers of samples in a limited time. This practice could affect test result quality, but yet no studies have determined whether this is the case. This study's purpose was to assess the effect of shortened counting duration (from either restricting counting time or counting only one grid of a slide) on McMaster test performance, and to compare the results to those of an automated test whose output is not subject to such limitations. Fifteen fecal samples from horses infected with strongylid parasites were divided equally into three groups based on high, medium and low levels of egg content (201-500, 501-1000 and 1001+ eggs/g). Slurries were produced from each sample and 10subsamples of each were counted by both the McMaster and automated methods. McMaster slides were first counted at leisure, and then twice again with counting time being restricted to either one or two min. The effect of reducing sample processing time by counting only one grid of the McMaster slide was also assessed. Counting for one min significantly decreased manual egg counts by 50-60% relative to counts conducted at leisure (p<0.001). While these decreases were somewhat ameliorated by counting for two min, the results were still approximately 10% lower than the at-leisure counts, a difference that was also statistically significant (p<0.001). Furthermore, restricted counting duration also resulted in a significant decrease of approximately one-third in McMaster test precision, as assessed by the coefficients of variation (CoVs) of the 10 replicates of each sample, as did counting just a single grid of the McMaster slide. These differences effectively further improved the observed superior precision of the automated method compared to at-leisure manual McMaster counting, and the automated counts and their precision remained relatively unaffected following multiple analyses of the same processed samples. Taken together, these results indicate that analysists should carefully assess the possible effects on test performance of modifications to standard egg-counting procedures that are designed to account for real-world pressures, in order to achieve an optimal compromise between test accuracy and precision on one hand and practicality on the other.

Determination of the specific gravity of eggs of equine strongylids, Parascaris spp., and Anoplocephala perfoliata.

Given the ever-increasing levels of anthelmintic resistance in livestock parasites globally, it is recommended to use parasite fecal egg counts to make treatment decisions and to evaluate treatment efficacy. The consensus in equine parasitology is to use a flotation medium with a specific gravity (SG) of ≥ 1.20 to float the main parasite egg types of interest in egg counting techniques. However, the density of common equine endoparasite eggs has been sparsely investigated. Equine tapeworm eggs are known to be particularly difficult to determine and count in fecal samples. It is unknown whether this could be because of differences in egg density. The aim of this study was to provide estimates of relative densities for equine ascarid, strongyle, and tapeworm eggs. Six aqueous glucose-salt solutions with specific gravities ranging from 1.06 to 1.16 were made and placed from most to least dense into thirteen 15 mL centrifuge tubes. Concentrated aqueous suspensions of the three types of endoparasite eggs were placed on top of each tube. These tubes were then centrifuged at 800 g for 20 min and each layer of flotation solution was carefully pipetted and transferred to a McMaster egg counting slide. Egg type and count were recorded for each specific gravity layer. Each egg was assigned a specific gravity based on the specific gravity layer it was observed in. In a second trial of this study, five similar flotation media were made ranging from 1.02 to 1.10 and were used in four subsequent replicates. In total between the two trials, the mean egg SGs of Anoplocephala perfoliata (n = 3811), Parascaris spp. (n = 3478), and strongylid type eggs (n = 9291) were 1.0636 (95% confidence interval (CI): 1.0629-1.0642), 1.0903 (95% CI: 1.0897-1.0909), and 1.0453 (95% CI: 1.0448-1.0458), respectively. The three egg types were statistically different from each other (p < 0.0001). This is the first time that the specific gravity of equine strongylid and Anoplocephala perfoliata eggs has been determined. With a tapeworm egg density demonstrated to be between that of strongylids and Parascaris spp., the poor recovery of tapeworm eggs in equine fecal samples must have other explanations.

Genipin crosslinker releasing sutures for improving the mechanical/repair strength of damaged connective tissue.

The most common mode of surgical repair of ruptured tendons and ligaments involves the use of sutures for reattachment. However, there is a high incidence of rerupture and repair failure due to pulling out of the suture material from the damaged connective tissue. The main goal of this research was to achieve a localized delivery of crosslinking agent genipin (GP) from rapid-release biodegradable coatings on sutures, for strengthening the repair of ruptured connective tissue. Our hypothesis is that GP released from the suture coating will lead to exogenous crosslinking of native connective tissue resulting in beneficial effects on clinically relevant mechanical parameters such as tear resistance, tissue strength, and energy required to rupture the tissue (toughness). Sutures were successfully coated with a biodegradable polymer layer loaded with the crosslinking agent genipin, without compromising the mechanical properties of the suture. The rapid-release of genipin was achieved under both in vitro and ex vivo conditions. Exogenous crosslinking using these genipin releasing sutures was demonstrated using equine tendons. The tendons treated with genipin releasing sutures showed significant improvement in failure load, energy required for pull-out failure, and stiffness. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 2199-2205, 2017.

Automated parasite faecal egg counting using fluorescence labelling, smartphone image capture and computational image analysis.

Intestinal parasites are a concern in veterinary medicine worldwide and for human health in the developing world. Infections are identified by microscopic visualisation of parasite eggs in faeces, which is time-consuming, requires technical expertise and is impractical for use on-site. For these reasons, recommendations for parasite surveillance are not widely adopted and parasite control is based on administration of rote prophylactic treatments with anthelmintic drugs. This approach is known to promote anthelmintic resistance, so there is a pronounced need for a convenient egg counting assay to promote good clinical practice. Using a fluorescent chitin-binding protein, we show that this structural carbohydrate is present and accessible in shells of ova of strongyle, ascarid, trichurid and coccidian parasites. Furthermore, we show that a cellular smartphone can be used as an inexpensive device to image fluorescent eggs and, by harnessing the computational power of the phone, to perform image analysis to count the eggs. Strongyle egg counts generated by the smartphone system had a significant linear correlation with manual McMaster counts (R(2)=0.98), but with a significantly lower coefficient of variation (P=0.0177). Furthermore, the system was capable of differentiating equine strongyle and ascarid eggs similar to the McMaster method, but with significantly lower coefficients of variation (P<0.0001). This demonstrates the feasibility of a simple, automated on-site test to detect and/or enumerate parasite eggs in mammalian faeces without the need for a laboratory microscope, and highlights the potential of smartphones as relatively sophisticated, inexpensive and portable medical diagnostic devices.

Thermal analysis reveals differential effects of various crosslinkers on bovine annulus fibrosis.

Treatment of a pathological spinal disc in vivo by injection of protein crosslinking reagents to restore the disc's mechanical properties is a new approach to the treatment of degenerative disc disease. In this study, the thermal stability of the collagen in disc annulus was measured by differential scanning calorimetry following treatment with six different crosslinking agents. The crosslinkers used were; L-threose (LT), genipin (GP), methylglyoxal (MG), 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide hydrochloride (EDC), glutaraldehyde (GA), and proanthrocyanidin (PA). Untreated tissue displayed a prominent peak at about 66-68°C. Comparison of endothermal patterns of untreated and crosslinker-treated disc annulus tissue samples showed that a new peak appeared at a higher temperature following treatment. The temperature of the new peak qualitatively depended on the crosslinker in the following order GA > MG > GP > PA = EDC > LT, suggesting that the enhanced thermal stability of collagen in the annulus tissue was related to the nature of the crosslinker. Also, the enthalpic ratios of the lower temperature (noncrosslinked) peaks in the treated and untreated tissue, and of the higher and lower temperature peaks in the treated tissue, both indicated that the various agents crosslinked the tissue with different efficiencies. Our data suggest that the ability of GP to penetrate into the disc and form long- and short-range crosslinks may make it the most suitable candidate for clinical development. In addition, binary combinations of long- and short-range crosslinkers, such as PA with LT, may also provide synergistic effects due to their substantially different physicochemical properties.

Optimization of protein crosslinking formulations for the treatment of degenerative disc disease.

STUDY DESIGN: Biochemical studies aimed at optimization of protein crosslinking formulations for the treatment of degenerative disc disease and subsequent biomechanical testing of tissues treated with these formulations. OBJECTIVE: To optimize protein crosslinking formulations for treatment of degenerating spinal discs. SUMMARY OF BACKGROUND DATA: Nonsurgical exogenous crosslinking therapy is a potential new, noninvasive technology for the treatment of degenerative disc disease. The technology is based on the injection of protein crosslinking reagents into the pathologic disc to restore its mechanical properties and also to potentially increase the permeability of the tissue and so facilitate the exchange of waste products and nutrients. METHODS: Diffusion of genipin (GP) was monitored following injection into spinal discs and the effects of surfactants on diffusion studied. Formulations for GP and methylglyoxal (MG) were biochemically optimized and used to treat bovine spinal discs. Their effects on bovine anulus tissue were evaluated using a circumferential tensile test, while the GP formulation was also tested with respect to its ability to reduce disc bulge under load. RESULTS: GP exhibited a distinct time-dependent diffusion and sodium-dodecyl-sulfate, but not Tween-20, enhanced diffusion by 30%. Two crosslinkers, GP and MG, were inhibited by amines but enhanced by phosphate ions. Both formulations could enhance a number of physical parameters of bovine anulus tissue, while the GP formulation could reduce disc bulge following injections into spinal discs. CONCLUSION: Formulations lacking amines and containing phosphate ions appear to be promising candidates for clinical use of the crosslinkers GP and MG.

Kinetic characterization and comparison of various protein crosslinking reagents for matrix modification.

We have characterized the relative efficacies of a number of protein crosslinking agents that have the potential for use in the crosslinking of proteinaceous matrices both in vitro and in vivo. The crosslinkers tested were; L: -threose (LT), Genipin (GP), Methylglyoxal (MG), 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide hydrochloride (EDC), proanthrocyanidin (PA) and glutaraldehyde (GA). The relative effectiveness of the crosslinkers with regard to their saturating concentrations was: GA > PA > EDC > MG = GP >> LT. Most of the crosslinkers displayed a pH dependence and were more effective at more alkaline pH. At optimal pH and saturating conditions, the relative reaction rates of the crosslinkers were: PA = GA > EDC > GP > MG >> LT.

Kinetic analysis of genipin degradation in aqueous solution.

Degradation of genipin (GP), a low toxicity natural protein crosslinking agent, in aqueous solution was monitored by HPLC at various pH levels. Degradation of GP was consistent with a mechanism consisting of a first order reaction with a reversible first step. Formation of the intermediate was slowest at more neutral pHs while formation of the irreversible product was correlated to increasing alkalinity. Degradation at all pHs was enhanced by the presence of phosphate ions. Degradation of GP most likely proceeds via the reversible opening of the dihydropyran ring by water followed by irreversible polymerization of the intermediate. Degraded solutions containing no detectable GP or intermediate, however, are still capable of crosslinking proteins.

Influence of papain urea copper chlorophyllin on wound matrix remodeling.

The purpose of this study was to examine the dermal and epidermal alterations associated with wound healing in wounds treated with papain urea copper chlorophyllin (PUC), papain-urea, copper chlorophyllin, or urea base ointment and compare these with moist wound care using a porcine full-thickness infected wound model. All the wounds were evaluated postsurgery for erythema, transepidermal water loss, microscopic morphology, and changes in protein expression. Examination of stained paraffin sections revealed an increase in the number of keratinocytes present in the epidermis of the PUC and papain-treated pigs, relative to moist control. This increase in keratinocyte number corresponded to an increase in the movement of the keratinocytes into the underlying dermis in the form of rete pegs. In the dermis, there appeared to be an increase in blood vessel formation, collagen I deposition, and mature collagen in the papain and PUC treated tissues. The quality of healing appears to be enhanced based on the number of keratinocytes present in the epidermis, the extensive rete peg formation, the increase in vasculature, and the increase in collagen birefringence.

High-affinity interactions between peptides and heat shock protein 70 augment CD8+ T lymphocyte immune responses.

Exogenously delivered antigenic peptides complexed to heat shock proteins (HSPs) are able to enter the endogenous Ag-processing pathway and prime CD8+ CTL. It was determined previously that a hybrid peptide containing a MHC class I-binding epitope and HSP70-binding sequence Javelin (J0) in complex with HSP70 could induce cytotoxic T cell responses in vivo that were more robust than those induced by the minimal epitope complexed with HSP70. The present study introduces a novel, higher-affinity HSP70-binding sequence (J1) that significantly enhances binding of various antigenic peptides to HSP70. A competition binding assay revealed a dissociation constant that was 15-fold lower for the H2-K(b) OVA epitope SIINFEKL-J1 compared with SIINFEKL-J0, indicating a substantially higher affinity for HSP70. Further, modifying the orientation of the hybrid epitope and introducing a cleavable linker sequence between the Javelin and the epitope results in even greater immunogenicity, presumably by greater efficiency of epitope processing. The enhanced immunogenicity associated with Javelin J1 and the cleavable linker is consistently observed with multiple mouse and human epitopes. Thus, by creating a series of epitopes with uniform, high-affinity binding to HSP70, successful multiple epitope immunizations are possible, with equal delivery of each antigenic epitope to the immune system via HSP70. These modified epitopes have the potential for creating successful multivalent vaccines for immunotherapy of both infectious disease and cancer.