Area contact networks and the spatio-temporal spread of infectious salmon anemia virus (ISAV) in Chile.

Area management, the coordination of production and biosecurity practices across neighboring farms, is an important disease control strategy in aquaculture. Area management in aquaculture escalated in prominence in response to outbreaks of infectious salmon anemia (ISA) internationally. Successes in disease control have been attributed to the separation achieved through area-level synchronized stocking, fallowing, movement restrictions, and fomite or pest control. Area management, however, is costly; often demanding extra biosecurity, lengthy or inconveniently timed fallows, and localization of equipment, personnel, and services. Yet, this higher-order organizational structure has received limited epidemiologic attention. Chile's National Fisheries and Aquaculture Service instigated area management practices in response to the 2007 emergence of ISA virus (ISAV). Longitudinal data simultaneously collected allowed retrospective evaluation of the impact of component tenets on virus control. Spatiotemporal analyses identified hydrographic linkages, shared ports, and fish transfers from areas with recent occurrence of ISAV as the strongest predictors of virus spread between areas, though specifics varied by ISAV type (here categorized as HPR0 for the non-virulent genotypes, and HPRv otherwise). Hydrographic linkages were most predictive in the period before implementation of enhanced biosecurity and fallowing regulations, suggesting that viral load can impact spread dynamics. HPR0 arose late in the study period, so few HPRv events were available by which to explore the hypothesis of HPR0 as progenitor of outbreaks. However, spatiotemporal patterns in HPRv occurrence were predictive of subsequent patterns in HPR0 detection, suggesting a parallel, or dependent, means of spread. Better data precision, breadth and consistency, common challenges for retrospective studies, could improve model fit; and, for HPR0, specification of diagnostic test accuracy would improve interpretation.

Field investigation of arsenic in ceramic pot filter-treated drinking water.

Ceramic pot filters (CPFs) is one of several household water treatment technologies that is used to treat drinking water in developing areas. The filters have the advantage of being able to be manufactured using primarily locally available materials and local labor. However, naturally-occurring arsenic present in the clay used to make the filters has the potential to contaminate the water in excess of the World Health Organization drinking water standard of 0.01 mg/L. A manufacturing facility in Guatemala routinely rinses filters to reduce arsenic concentrations prior to distribution to consumers. A systemic study was performed to evaluate the change in arsenic concentrations with increasing volumes of rinse water. Arsenic field kit results were compared to standard method laboratory results, and dissolved versus suspended arsenic concentrations in CPF-treated water were evaluated. The results of the study suggest that rinsing is an effective means of mitigating arsenic leached from the filters, and that even in the absence of a formal rinsing program, routine consumer use may result in the rapid decline of arsenic concentrations. More importantly, the results indicate that filter manufacturers should give strong consideration to implementing an arsenic testing program.

Fur and iron transport proteins in the Brazilian purpuric fever clone of Haemophilus influenzae biogroup aegyptius.

The Brazilian purpuric fever (BPF) clone of Haemophilus influenzae biogroup aegyptius causes a fatal septicaemic disease, resembling fulminant meningococcal sepsis, in children. When isolate F3031 was grown under iron-limiting conditions, the presence of several iron-regulated proteins of 38-110 kDa was revealed by electrophoretic analysis and a Fur homologue was shown by immunoblotting. Dot-blot assays and immunoblotting indicated that BPF cells bound human transferrin and contained transferrin-binding proteins in the outer membrane. However, the binding activity and the biosynthesis of these proteins were detected even under iron-rich conditions. Immunoblot analysis demonstrated the presence of a periplasmic protein related to the ferric iron-binding protein A (FbpA), the major iron-binding protein described in Neisseria spp. However, the FbpA homologue in strain F3031 was constitutively expressed and was smaller than the periplasmic protein detected in H. influenzae type b strain Eagan. The periplasm of strain F3031 also contained a protein related to the Streptococcus parasanguis FimA protein which recently has been shown to be involved in iron acquisition in Yersinia pestis. Although the Eagan and F3031 FimA homologues had a similar mol. wt, of 31 kDa, the expression of the BPF fimA-like gene was not regulated by the iron concentration of the culture medium.

Molecular and genetic analysis of iron uptake proteins in the brazilian purpuric fever clone of Haemophilus influenzae biogroup aegyptius.

Haemophilus influenzae biogroup aegyptius (H. aegyptius) is the etiological agent of Brazilian purpuric fever (BPF), a recently described pediatric disease that is often fatal. The vascular destruction that occurs in this disease is a distinctive trait, and little is known about the mechanism(s) of the overwhelming purpura fulminans that causes the high mortality associated with this pediatric infection. Iron is an essential micronutrient for nearly all living cells, and the mechanisms used by bacteria to acquire and internalize iron are often associated with virulence. Therefore, the focus of our studies is the molecular characterization of the iron uptake system used by H. aegyptius. Specifically, we are investigating the high-affinity transferrin binding proteins in the bacterial outer membrane, components of ABC transporter systems, and a possible regulatory mechanism for the genes encoding these proteins. A detailed understanding of the molecular nature of the regulatory genetic components and proteins involved in the acquisition of iron will broaden the knowledge of the pathogenesis of the disease caused by H. aegyptius and will also lead to a better understanding of the nature of other infections that affect the vascular system.

Transient surfactant protein B deficiency in a term infant with severe respiratory failure.

A 38-day-old male infant with persistent pulmonary hypertension and respiratory failure since birth was found to have a complete absence of surfactant protein B (SP-B) along with an aberrant form of SP-C in his tracheal aspirate fluid, findings consistent with the diagnosis of hereditary SP-B deficiency. Surprisingly, SP-B and SP-B messenger ribonucleic acid were present in lung biopsy tissue. However, DNA sequence analysis demonstrated a point mutation in exon 5 of one of the SP-B gene alleles. The infant's mother was found to be a carrier of this mutation. The infant's other SP-B allele did not differ from the published DNA sequence for the SP-B gene. We conclude that this patient had a transient deficiency of SP-B, in contrast to that of previously described infants with irreversible respiratory failure caused by hereditary SP-B deficiency. We recommend that infants with suspected SP-B deficiency have serial analysis of tracheal fluid samples for both SP-B and SP-C before lung biopsy, along with genetic analysis for the known SP-B mutations. We speculate that the new mutation found in one of this patient's SP-B genes was in part responsible for the transient deficiency of SP-B.

Changing patterns of red blood cell transfusion in very low birth weight infants.

OBJECTIVE: Anemia develops in increasing numbers of critically ill very low birth weight (VLBW) infants who survive the neonatal period, and they receive multiple red blood cell (RBC) transfusions. Despite their need for prolonged medical treatment, we hypothesized that VLBW infants presently receive fewer RBC transfusions as a result of the growing awareness of transfusion risks and improvement of neonatal care. METHODS: RBC transfusion practices and clinical outcomes in infants with birth weights of 1.5 kg or less were analyzed retrospectively in three selected years: 1982, before awareness of the human immunodeficiency virus; 1989, before surfactant availability; and 1993, before erythropoietin approval. RESULTS: Progressive declines in RBC transfusions, donor exposures, and transfusion volumes occurred concurrently with decreases in morbidity and mortality rates. Transfusions per infant (mean +/- SD) declined from 7.0 +/- 7.4 in 1982 to 5.0 +/- 5.8 in 1989 to 2.3 +/- 2.7 in 1993 (p < 0.001). This decline was associated with a decrease in pretransfusion hematocrit (33.6% +/- 2.8% in 1982, 34.2% +/- 3.7% in 1989, and 29.8% +/- 5.1% in 1993; p < 0.001). The distribution of RBC transfusions given by week of life among study years did not change; 70% of RBC transfusions were given within the first 4 weeks, when infants are sickest. Although the percentage of VLBW infants weighing more than 1 kg at birth and never receiving any RBC transfusions increased with time (17% in 1982, 33% in 1989, and 64% in 1993), more than 95% of infants weighing 1 kg or less in all years received transfusions. CONCLUSIONS: Overall administration of neonatal transfusions has decreased markedly, most likely because of multiple factors. Because most RBC transfusions are given to infants weighing 1 kg or less in the first weeks of life, therapeutic strategies should focus on this group of VLBW infants during this critical period. The temporal changes observed in transfusion patterns emphasize the importance of including concurrent controls in future studies evaluating transfusion interventions.

The contrasting effects of CD8+ T cells on primary, established and Nippostrongylus brasiliensis-induced IgE responses.

Recent data have indicated that CD8+ T cells suppress rodent IgE responses. In this study we investigated the effect of CD8+ T cells on primary and established IgE responses in euthymic and athymic nude rats. Euthymic PVG rats were depleted of CD8+ T cells by intraperitoneal injection of a CD8-specific monoclonal antibody (OX8), which resulted in an apparent loss of 92% of splenic and 98% of peripheral blood CD8+ T cells. The CD8+ T-cell depleted animals failed to mount a significant IgE response compared with control animals given an irrelevant monoclonal antibody (OX21). Furthermore, PVG nude rats reconstituted with purified CD4+ thoracic duct lymphocytes (TDL) alone failed to mount a significant IgE response, while animals given unfractionated TDL (containing CD4+ and CD8+ T cells) did. Depletion of CD8+ T cells 7 days prior to immunization and subsequent reconstitution at the time of immunization restored the IgE response. In contrast, removal of CD8+ T cells 1 month after induction of IgE by immunization with ovalbumin (OVA) and ricin prolonged the IgE response. In all cases IgG antibody responses were unaffected by the presence or absence of CD8+ T cells. This study shows that some CD8+ T cells are required for IgE, but not IgG, production to soluble antigen in a primary immune response. However, later in the immune response CD8+ T cells were shown to inhibit IgE production. These effects were apparently restricted to the immune response to soluble antigen, as Hooded Lister rats infected with 9000 larvae of the nematode Nippostrongylus brasiliensis produced high sustained levels of circulating IgE, in excess of 10 micrograms/ml, regardless of whether CD8+ T cells were depleted before or 1 month after infection.

Lessons from Cuba: mass campaign administration of trivalent oral poliovirus vaccine and seroprevalence of poliovirus neutralizing antibodies.

The immunogenicity of trivalent oral poliovirus vaccine (TOPV), which is less effective in tropical than in temperate areas, may potentially be improved in several ways, including increasing the number of doses. Little information is available on TOPV when more than 6 doses are given. The situation in Cuba provides a unique opportunity to relate the seroprevalence of neutralizing antibodies to the dose of TOPV because Cuba has not reported culture-confirmed poliomyelitis since 1973 and TOPV is only administered in twice yearly 1-week mass immunization campaigns. Sera from 2000 children nationwide were studied for neutralizing antibody among children who received 0, 2, 4, 6 and 8 doses of TOPV. These doses were administered in the period 1989-91, when TOPV (from the USSR) was being used with 500,000, 200,000, and 300,000 median tissue-culture-infecting doses (TCID50) for types 1, 2 and 3, respectively--the 5:2:3 formulation. Seroprevalence of neutralizing antibody after two TOPV doses was 91.5% for type 1, 90.8% for type 2, and 45.9% for type 3. Seroprevalence of type-3 neutralizing antibody after 6 doses remained low (73.4%), but increased to 83.5% after 8 doses (P < 0.05). Although 16.5% of the children remained unprotected for type-3 infection even after 8 doses, mass campaign immunization strategies were sufficient to eradicate the transmission of wild poliovirus in Cuba. Because the seroprevalence of type-1 neutralizing antibody was high (91.5%) after two campaign doses, additional studies using different formulations are needed to determine whether simultaneous improvement in the type-3 response to two campaign doses can be achieved.

PIP: During December 1991-January 1992 in Cuba, health workers took blood samples from a nationwide sample of 2000 children aged 0-3 who received 0, 2, 4, 6, and 8 doses of trivalent oral poliovirus vaccine (TOPV) to determine the seroprevalence of poliovirus neutralizing antibodies for types 1, 2, and 3. Specifically, researchers wanted to learn whether TOPV becomes more effective as the number of doses increases. Since 1973, Cuba has conducted two mass immunization campaigns each year in February and April. During 1970-91, Cuba used a USSR-produced poliovirus vaccine that had 500,000, 200,000, and 300,000 median tissue-culture-infecting doses for types 1, 2, and 3, respectively. Wild poliovirus has not been transmitted in Cuba since 1973 (as of August 1993), indicating that the mass immunization campaigns without routine vaccine delivery have eradicated poliomyelitis in Cuba. The seroprevalence of poliovirus neutralizing antibodies for type 1 increased significantly between 2 and 4 doses (91.5% vs. 96.5%; p = 0.05), thereafter the increases were small and insignificant. The seroprevalence of poliovirus neutralizing antibodies for type 2 increased significantly between 2 and 4 doses (90.8% vs. 97.2%), with small insignificant increases thereafter. Two doses of TOPV induced a response against poliovirus type 3 in only 45.9% of cases. At 4 doses and 8 doses, it did increase significantly from the previous dose (71.2% and 83.5%, respectively; p 0.05). Further studies using other vaccine formulations would allow persons involved in global eradication efforts to determine whether two campaign doses can improve the immunogenicity of the type 3 poliovirus while also improving that of the type 1 poliovirus.

Addition of metolazone to overcome tolerance to furosemide in infants with bronchopulmonary dysplasia.

A decreased response to the loop diuretic furosemide develops within a few doses in young infants. We tested the hypothesis that the use of the thiazide-like diuretic metolazone, in combination with furosemide, would inhibit water and electrolyte reabsorption and overcome pharmacologic tolerance to furosemide alone. Infants with bronchopulmonary dysplasia of similar gestational and postnatal ages were randomly assigned to one of three groups. Group 1 (n = 6) received furosemide (1 mg/kg per dose) intravenously every 24 hours for a total of five doses. Group 2 (n = 8) received the same treatment as group 1, but in addition metolazone (0.2 mg/kg per dose) was given enterally with doses 3 and 4 of furosemide. Group 3 (n = 8) received metolazone (0.2 mg/kg per dose) enterally every 24 hours for five doses. Urine was collected before the first diuretic dose and throughout the study for determination of the urine flow rate; urinary excretion of sodium, chloride, and potassium; and creatinine clearance. Urinary flow rate and urinary sodium and chloride excretion increased after the first dose in all groups. In the infants treated with either furosemide or metolazone, urinary flow rate and urinary and chloride excretion returned to baseline values after the last three doses. In contrast, when furosemide was administered with metolazone, urinary flow rate and urinary excretion of sodium, chloride, and potassium were greater than the values for baseline and for the previous dose, as well as for the corresponding doses of furosemide in group 1 and metolazone in group 3. Tolerance to furosemide (group 1) and metolazone (group 3) appeared to be explained by compensatory increased sodium and chloride reabsorption without changes in creatinine clearance. We conclude that the administration of metolazone with furosemide enhances diuresis, natriuresis, and chloruresis and overcomes the rapid development of tolerance to furosemide in infants with bronchopulmonary dysplasia by blocking the compensatory increase in renal sodium and chloride absorption.

Effects of formula temperature on postprandial thermogenesis and body temperature of premature infants.

To study the effect of formula temperature on the thermogenic response to gavage feeding, we fed formula at room temperature (mean 24.0 degrees C, SD 1.1) and at body temperature (mean 36.9 degrees C, SD 1.7) to premature infants in a crossover design while monitoring their metabolic heat production and gastric, rectal, and skin temperatures. After feeding with room temperature formula, stomach temperature fell by 6.9 degrees C, rectal temperature by 0.2 degree C, and mean skin temperature by 0.6 degree C, and metabolic rate increased by 16% in the first postprandial hour. After body temperature feedings, mean skin temperature fell by 0.2 degree C, but stomach and rectal temperatures did not change appreciably. The metabolic rate rose by 12% in the first hour, which was not significantly less than the rise after room temperature feeding. The heat required to warm the formula to body temperature did not result in a detectably greater rise in metabolic rate after cool feeding than after warm feeding. The effects of feed temperatures below room temperature were not studied, but it remains possible that cooler feedings might produce even greater body cooling and a greater thermogenic response.

Accelerated elimination of N. brasiliensis from the small intestine after auto-anti-IgE induction.

Immunization of rats with a purified IgE myeloma (IR2) induced an auto-anti-IgE response. Such treatment inhibited total IgE levels in the serum of conventional IgE-producing rats (Marshall & Bell, 1985) and increased the number of mucosal mast cells (MMC) in the intestine. The present study has investigated the ability of auto-anti-IgE induction to influence the course of a Nippostrongylus brasiliensis infection, to modify IgE synthesis, or to affect the number of MMC in the intestine following infection. Auto-anti-IgE induction was found to have a surprising effect on worm elimination. IR2-immunized rats were able to rid themselves of this nematode with an accelerated tempo--a small but significant effect after primary infection, but a substantial enhancement of worm loss after reinfection. Auto-anti-IgE induction was not able to prevent the typical increase in IgE that accompanies an N. brasiliensis infection, nor did it alter the helminth-induced intestinal mastocytosis. When MMC degranulation was measured by assaying the serum levels of a specific rat mast protease (RMCP II) following secondary infection, the amount of RMCP II released was less in auto-anti-IgE-producing rats. These findings have implications for the importance of IgE, MMC and other cells of inflammation in an anti-parasitic response.

Effects of environmental warming on blood components dispensed in syringes for neonatal transfusions.

We examined the quality of blood components dispensed in syringes for transfusion into neonates, including the effects on quality of environmental conditions to which blood is exposed when it is transfused into neonates nursed in warm-air incubators or under radiant warmers. Syringes of blood placed in incubators rapidly warmed to 36 degrees C. Blood placed under radiant warmers operated at full power was heated rapidly to temperatures approaching 45 degrees C, and all blood components exhibited evidence of falling pH and cellular damage after 6 hours exposure to radiant energy. Erythrocyte damage was suggested by an increase in plasma hemoglobin, potassium, and lactic dehydrogenase. Platelets lost the ability to recover from hypotonic shock. Granulocytes exhibited a marked defect in the ability to produce superoxide anion after stimulation. The excessive warming and functional abnormalities exhibited by all blood components exposed to infrared energy were abrogated when syringes were shielded by covering them with aluminum foil. The clinical importance of these experimental findings remains to be established. Meanwhile, it would seem prudent either to shield syringes of blood placed under radiant warmers by covering them with aluminum foil or to limit the volume of a single transfusion to a quantity that can be infused within a relatively brief period.

Temperature measurement in term and preterm neonates.

Body temperatures of 99 term and 44 preterm infants were measured at four sites: core (5 cm beyond the anus, with an electronic telethermometer), rectum (2 cm, with a mercury-in-glass thermometer), axilla, and between the skin and mattress. Temperatures measured at the four sites agreed closely in this group of largely normothermic infants. However, five of seven term infants with abnormal core temperature (greater than 1.5 SD below or above the mean) would have been judged to be normothermic by each of the three other measurements. The temperatures in preterm infants were lower and varied less with the site of measurement, indicating a smaller core-surface temperature gradient because of their relative lack of thermal insulation by body fat. Axillary temperature was as reliable as rectal temperature measured in the usual way with a mercury-in-glass thermometer. Measurement of the temperature between the skin and mattress was nearly as accurate as the other more frequently used methods. Ninety percent of temperatures were within 0.1 degree C of their final stabilization readings by 5 minutes for each type of thermometer and measurement site.

Air versus skin temperature servocontrol of infant incubators.

Air temperature servocontrol was compared with skin temperature servocontrol and manual control as methods for regulating the heat output of a single-walled incubator (Air-Shields C-86) (1) when optimally used in the laboratory and (2) when operated by staff nurses in the nursery. The subjects were eight premature infants with birth weights between 1.07 and 1.54 kg. When the three methods were used to produce neutral air and skin temperatures during 2-hour measurement periods in the laboratory, there were no differences in mean air, skin, or rectal temperature, metabolic heat production, or body heat loss. There were also no differences among the three methods in mean air, skin, or rectal temperature when used by the nurses in the nursery for periods of 24 hours. When incubator wall temperature is stable, air temperature servocontrol can be used as effectively as skin temperature servocontrol to operate infant incubators.

The effects of thermal environment on heat balance and insensible water loss in low-birth-weight infants.

To define the neutral environmental temperature and assess the effects of deviation from that temperature on insensible water loss and heat balance, 12 premature infants were studied in a conventional incubator at four different predetermined ambient temperatures. Our method combines insensible water loss measured by a continuous read-out electronic scale with heat production as determined by open circuit measurement of oxygen consumption. An increase of 1 to 2 degrees C, to an ambient temperature above or near the top of the neutral zone, produced a significant rise in insensible water loss, from 1.90 +/- 0.76 to 3.08 +/- 1.19 ml/kg/hour (mean +/- SD), a corresponding rise in evaporative heat loss, and a fall in nonevaporative heat loss. A decrease of 1 to 2 degrees C, to a slightly subneutral ambient temperature, resulted in an increase in oxygen consumption from 5.82 +/- 0.92 to 7.45 +/- 1.50 ml/kg/minute, and an increase in total heat loss, but no change in insensible water loss and evaporative heat loss. The increased total heat loss was judged to be due entirely to a greater nonevaporative heat loss, both by convection and by radiation. The data confirm that ambient temperature is an important determinant of the magnitude and the partition of heat loss in low-birth-weight infants.

Heat balance in premature infants: comparative effects of convectively heated incubator and radiant warmer, with without plastic heat shield.

Insensible water loss, oxygen consumption, and carbon dioxide production were measured in eight premature infants under four different conditions: in conventional single-walled incubator with and without plastic heat shield, and under radiant warmer with and without heat shield. IWL was greater under the radiant warmer (3.40 +/- 1.50 ml/kg/hour, mean +/- SD) than in the incubator (2.37 +/- 1.15 ml/kg/hour) when both were compared without heat shield. Addition of the heat shield reduced IWL in the incubator (2.13 +/- 0.76 ml/kg/hour) but not under the radiant warmer (3.37 +/- 0.94 ml/kg/hour). There were no significant differences in VO2 or respiratory quotient between any two of the four study conditions.