Burden of pertussis among young infants in Malaysia: A hospital-based surveillance study.

BACKGROUND: The case fatality rate and the risk of complications due to pertussis is very high in infants. Asia has the second highest childhood pertussis burden. The study aimed to assess the prevalence, clinical complications, and mortality rates of pertussis disease requiring hospitalization among young infants in Malaysia. METHODS: The study was a one-year, hospital-based, multi-site surveillance of infants less than six months of age with symptoms consistent with pertussis and a cross-sectional analysis of their mothers for recent pertussis infection. Information was obtained from medical records and interviews with the parents. Pertussis diagnosis was confirmed for all infants through serum anti-PT titration test or PCR test. RESULTS: 441 possible cases of pertussis were included in this study. Of these, 12.7 % had laboratory confirmation of pertussis. Infants with confirmed pertussis had significantly higher rates of cyanosis (37.5 % vs 8.6 %; p < 0.0001) and apnea (12.5 % vs 3.9 %; p = 0.027) than test-negative infants. Most infants from both groups were in recovery/recovered at discharge. Those with confirmed pertussis had higher case fatality rate than test-negative cases (5.4 % vs 1.0 %; p = 0.094), but the difference did not reach significance. The majority of confirmed pertussis cases (89.3 %) occurred in infants too young to be fully vaccinated or under-vaccinated for their age. Both test-negative and confirmed pertussis resulted in work-day losses and incurred costs for both parents. CONCLUSIONS: A high pertussis disease burden persists in infants less than six months of age, especially among those un- and under-vaccinated. Maternal and complete, on-time infant vaccination is important to reduce disease burden.

Detection of enteroviruses during a 2018 hand, foot and mouth disease outbreak in Malaysia.

Hand, foot, and mouth disease (HFMD) is a common childhood disease caused by enteroviruses. In 2018, a HFMD outbreak in Malaysia affected over 76,000 children. In this study, we used RT-qPCR and CODEHOP PCR to detect the causative agents in 89 clinically diagnosed HFMD patients in Kuala Lumpur and Selangor. Most (62.9%) of the children were below 3 years old. PCR with either assay detected enteroviruses in 84.2% (75/89) and CODEHOP PCR successfully typed 66.7% (50/75) of the enteroviruses. Sequencing of CODEHOP amplicons showed co-circulation of multiple enteroviruses with coxsackievirus A6 (CV-A6) and A16 as the predominant serotypes, but not the neurovirulent enterovirus A71. CV-A6 infection was more common in children less than 12 months old (p=0.01) and was more likely to cause vesicles in the gluteal area (p=0.01) compared to other enteroviruses. Establishing a robust identification method during HFMD outbreaks is important for patient management and public health responses.

Detection of enteroviruses during a 2018 hand, foot and mouth disease outbreak in Malaysia

@#Hand, foot, and mouth disease (HFMD) is a common childhood disease caused by enteroviruses. In 2018, a HFMD outbreak in Malaysia affected over 76,000 children. In this study, we used RT-qPCR and CODEHOP PCR to detect the causative agents in 89 clinically diagnosed HFMD patients in Kuala Lumpur and Selangor. Most (62.9%) of the children were below 3 years old. PCR with either assay detected enteroviruses in 84.2% (75/89) and CODEHOP PCR successfully typed 66.7% (50/75) of the enteroviruses. Sequencing of CODEHOP amplicons showed co-circulation of multiple enteroviruses with coxsackievirus A6 (CV-A6) and A16 as the predominant serotypes, but not the neurovirulent enterovirus A71. CV-A6 infection was more common in children less than 12 months old (p=0.01) and was more likely to cause vesicles in the gluteal area (p=0.01) compared to other enteroviruses. Establishing a robust identification method during HFMD outbreaks is important for patient management and public health responses.

Causative agents of hand, foot and mouth disease in University Malaya Medical Centre, Kuala Lumpur, Malaysia in 2012-2013.

Hand, foot and mouth disease (HFMD) is a childhood illness, commonly caused by enterovirus A71 (EV-A71) and coxsackievirus A16 (CV-A16). In recent years, unusual HFMD outbreaks caused by coxsackievirus A6 (CV-A6) have been reported. From May 2012 to September 2013, enteroviruses were detected in 25 HFMD patients in University Malaya Medical Centre, Kuala Lumpur, Malaysia. The predominant serotypes were EV-A71 (48%) and CV-A6 (48%), followed by CV-A16 (4%). CV-A6 patients (mean age, 2.1) were significantly younger than EV-A71 patients (mean age, 3.3). There were no significant differences observed in clinical features between EV-A71 and CV-A6 patients. Since enteroviruses are difficult to differentiate clinically, the conserved 5' untranslated region (5' UTR) was used to identify enterovirus serotypes. Phylogenetic analysis of 5' UTR showed distinct clustering of viruses as EV-A71, CV-A16 and CV-A6. Further genotyping with capsid genes showed that all the EVA71 sequences belonged to subgenotype B5, while the CV-A16 sequence belonged to subgenotype B2b. CV-A6 sequences were clustered into genotypes D1 and D2, with recent isolates from Seri Kembangan, Malaysia and China. In summary, 59.5% of HFMD cases in our centre in 2012-2013 were caused by EV-A71, CV-A16 and the newly emerging CV-A6. This study also demonstrated that 5' UTR is suitable for preliminary identification of enteroviruses during HFMD outbreaks, but specific capsid genes such as VP1 and VP4/VP2 are required for further genotyping. Apart from measures to control the spread of the virus during an outbreak of HFMD, identification of EV-A71 as the etiological agent is important as EV-A71 is a major cause of severe neurological complications and potentially fatal.

Diagnosis of human enterovirus A71 infection in Malaysia using a commercial IgM-capture enzyme-linked immunosorbent assay and an IgM-colloidal gold immunochromatographic assay.

Hand, foot and mouth disease (HFMD) is a common childhood infection caused by many enteroviruses, including enterovirus A71 (EV-A71). As EV-A71 is associated with severe neurological disease, early diagnosis is critical for clinical and public health management. In developing countries such as Malaysia, laboratory capacity to carry out EV-A71 IgM detection is greater than that of the gold standard methods of virus culture or molecular detection. This study evaluated two diagnostic kits, EV-A71 IgM-capture enzyme-linked immunosorbent (ELISA) and EV-A71 IgM-colloidal gold immunochromatographic assay (GICA), which had previously only been assessed in China. The assays were tested with 89 serum samples from patients with suspected HFMD. The sensitivity, specificity, positive predictive value, and negative predictive value rates were 78.4%, 80.8%, 74.4%, and 84.0%, respectively, for the IgM-capture ELISA, and 75.7%, 76.9%, 70.0%, and 81.6% for the IgM GICA. These performance measures were similar between the two assays. Concordance between the two assays was 91.1%. The sensitivity rates were lower than those previously reported, likely because the multiple circulating EV-A71 genotypes in Malaysia differ from the C4 subgenotype found in China and used in the assays. Both assays had low false positive rates (12.5% and 16.7% for ELISA and GICA, respectively) when tested on sera from patients confirmed to have enteroviruses. Both diagnostic kits are suitable for early diagnosis of HFMD caused by EVA71 in Malaysia, but confirmation with culture or PCR is still important.

Under-recognized pertussis in adults from Asian countries: a cross-sectional seroprevalence study in Malaysia, Taiwan and Thailand.

Surveillance data on the burden of pertussis in Asian adults are limited. This cross-sectional study evaluated the prevalence of serologically confirmed pertussis in adults with prolonged cough in Malaysia, Taiwan and Thailand. Adults (⩾19 years) with cough lasting for ⩾14 days without other known underlying cause were enrolled from outpatient clinics of seven public and/or private hospitals. Single blood samples for anti-pertussis toxin antibodies (anti-PT IgG) were analysed and economic impact and health-related quality of life (EQ-5D) questionnaires assessed. Sixteen (5·13%) of the 312 chronically coughing adults had serological evidence of pertussis infection within the previous 12 months (anti-PT IgG titre ⩾62·5 IU/ml). Three of them were teachers. Longer duration of cough, paroxysms (75% seroconfirmed, 48% non-seroconfirmed) and breathlessness/chest pain (63% seroconfirmed, 36% non-seroconfirmed) were associated with pertussis (P < 0·04). Of the seroconfirmed patients, the median total direct medical cost per pertussis episode in public hospitals (including physician consultations and/or emergency room visits) was US$13 in Malaysia, US$83 in Taiwan (n = 1) and US$26 in Thailand. The overall median EQ-5D index score of cases was 0·72 (range 0·42-1·00). Pertussis should be considered in the aetiology of adults with a prolonged or paroxysmal cough, and vaccination programmes considered.

Compound heterozygous mutations in TTC7A cause familial multiple intestinal atresias and severe combined immunodeficiency.

Familial multiple intestinal atresias is an autosomal recessive disease with or without combined immunodeficiency. In the last year, several reports have described mutations in the gene TTC7A as causal to the disease in different populations. However, exact correlation between different genotypes and various phenotypes are not clear. In this study, we report identification of novel compound heterozygous mutations in TTC7A gene in a Malay girl with familial multiple intestinal atresias and severe combined immunodeficiency (MIA-SCID) by whole exome sequencing. We found two mutations in TTC7A: one that destroyed a putative splicing acceptor at the junction of intron 17/exon 18 and one that introduced a stop codon that would truncate the last two amino acids of the encoded protein. Reviewing the recent reports on TTC7A mutations reveals correlation between the position and nature of the mutations with patient survival and clinical manifestations. Examination of public databases also suggests carrier status for healthy individuals, making a case for population screening on this gene, especially in populations with suspected frequent founder mutations.

Nutritional status of children living with HIV and receiving antiretroviral (ARV) medication in the Klang Valley, Malaysia.

INTRODUCTION: Nutrition and HIV are closely related. Any immune impairment as a result of HIV leads to malnutrition, which in turn, can also lead to reduced immunity, thus contributing to a more rapid progression to AIDS. METHODS: This cross-sectional study determined the nutritional status of children living with HIV and are receiving antiretroviral medication in the Klang Valley. A total of 95 children aged one to eighteen years old were recruited between September 2008 and February 2009. Data collected included socio-economic status, anthropometric measurements, dietary intake, medical history and serum levels of selected micronutrients specific for immunity. RESULTS: The mean age of the children was 8.4 +/- 3.9 years and the mean duration on antiretroviral medications was 68.3 +/- 38.3 months. Anthropometric assessment found that 9.5% of the children were underweight and 31.6% were overweight. In contrast, 20.8% were stunted and 14.6% severely stunted. Biochemical indicators showed that 10.4% had deficiency in vitamin A while 12.5% had deficiency in selenium. Total cholesterol and HDL-C levels were found to be low in 30.5% and 10.5% of the children respectively. CONCLUSION: Dietary assessment showed almost all the children did not achieve the recommended energy intake for their age groups and almost half of the children did not achieve the RNI for selenium and vitamin A. This study provides an insight on the nutritional status of children living with HIV.

Preadaptation to the feeding schedule does not eliminate activity-based anorexia in rats.

To test whether activity-based anorexia (ABA) still occurs after preadaptation to the feeding schedule, 20 rats were first exposed to a feeding schedule of one 90-min meal per day until adaptation occurred (measured by maintenance of stable body weight). Then, during ABA training, half the rats (wheel group) were confined in running wheels except during the daily meal, and half (cage group) were not. Wheel running suppressed feeding--that is, food intake in the wheel group was less than that in the cage group. Also, the rats in the wheel group lost weight, whereas those in the cage group did not. Wheel running increased over days. Thus, the defining characteristics of ABA were evident in rats that were not subjected to ABA training until after they had become well adapted to the feeding schedule. These findings support the view that the suppression of feeding produced by wheel running triggers the vicious circle of ABA. They also cast doubt on the hypothesis that activity-induced interference with adaptation to the feeding schedule plays a key role in causing ABA.

NaCl detection thresholds: comparison of Fischer 344 and Wistar rats.

Adult Fischer 344 (F344) rats fail to display any preference for NaCl solutions at concentrations typically preferred by other rat strains. To determine whether this behavior is due to a strain difference in NaCl detection threshold, a conditioned taste aversion (CTA) was first established to a suprathreshold concentration of NaCl (0.1 M). Then, a series of dilute NaCl solutions, ranging from 0.0 to 0.011 M NaCl, were presented to F344 (n = 16) and Wistar (n = 16) rats. The lowest concentration at which there was a reliable difference in the preference scores of conditioned and control rats was defined as the detection threshold. Results indicate that the detection threshold for NaCl lies between 0.001 and 0.002 M NaCl for both F344 and Wistar rats. The addition of the sodium channel blocker amiloride to the NaCl solutions raised the detection threshold 10-fold to 0.03-0.04 M NaCl for both strains of rats. These results suggest that the NaCl detection thresholds of F344 and Wistar rats are similar and that these strains do not differ in the degree to which amiloride raises this threshold.

Naloxone attenuates the conditioned place preference induced by wheel running in rats.

Pairings, during which an episode of wheel running is followed by confinement in a distinctive place, produce conditioned place preference (CPP) in rats. This finding indicates that wheel running has a rewarding effect that outlasts the activity itself. In two similar experiments, we tested the hypothesis that this rewarding effect of wheel running is mediated by endogenous opioids. During a paired trial, the rats in the naloxone group were first allowed to wheel run for 2 h, then injected with naloxone (0.5 or 0.1 mg/kg in Experiments 1 and 2, respectively), and 10 min later placed in a distinctive chamber. During an unpaired trial, these rats were confined in an adjoining chamber without wheel running. Naloxone was injected before placement in both chambers, so that if naloxone-induced conditioned place aversion occurred, it would have counteracting effects on performance during the preference test. The rats in the saline group were similarly treated, except that saline was injected instead of naloxone. CPP occurred in the saline group, but not in the naloxone group. Thus, naloxone attenuated the CPP induced by wheel running. This finding supports the hypothesis that the rewarding effect of wheel running is mediated by endogenous opioids.

Factor V inhibitor in neonatal intracranial hemorrhage secondary to severe congenital factor V deficiency.

We report a newborn infant girl, born to consanguineous parents, with recurrent intracranial hemorrhage secondary to congenital factor V deficiency with factor V inhibitor. Repeated transfusions of fresh-frozen plasma (FFP) and platelet concentrates, administrations of immunosuppressive therapy (prednisolone and cyclophosphamide), and intravenous immunoglobulin failed to normalize the coagulation profiles. Exchange transfusion followed-up by administrations of activated prothrombin complex and transfusions of FFP and platelet concentrates caused a temporary normalization of coagulation profile, enabling an insertion of ventriculoperitoneal (VP) shunt for progressive hydrocephalus. The treatment was complicated by thrombosis of left brachial artery and ischemia of left middle finger. The child finally died from another episode of intracranial hemorrhage 10 days after insertion of the VP shunt.

Acquired immunodeficiency syndrome presenting as childhood non-Hodgkin's lymphoma.

Two children with non-Hodgkin's lymphoma (NHL) as the presenting illness of acquired immunodeficiency syndrome (AIDS) are described. There was a delay in diagnosing the underlying AIDS in both cases. In the first case, an 18-month-old boy with stage IV, high-grade,T-cell NHL, the diagnosis of underlying AIDS was suspected only when he developed recurrent and profound opportunistic infection during chemotherapy. The second case, an eight-month-old female infant presented initially with hepatosplenomegaly and thrombocytopenia of undetermined cause. She had progressive abdominal distension and swelling of her right eye one year later due to high grade B-cell NHL. She was later found to be sero-positive for HIV during pre-chemotherapy screening. As the prevalence of HIV infection continues to increase, HIV infection should be considered in the differential diagnoses of childhood hepatosplenomegaly and thrombocytopenia, and as a possible underlying cause of childhood cancer, especially NHL.

The predictive value of uvulo-palatoglossal junctional ulcers as an early clinical sign of exanthem subitum due to human herpesvirus 6.

BACKGROUND: The clinical sign of uvulo-palatoglossal junctional (UPJ) ulcers was first noted in 1983 in a 5.5-month-old baby with exanthem subitum (ES). An earlier prospective clinical study showed that there was a strong association of UPJ ulcers and occurrence of ES with a positive predictive value of 95.3% and negative predictive value of 100%. OBJECTIVE: To determine the value of uvulo-palatoglossal junctional (UPJ) ulcers as an early clinical sign of exanthem subitum (ES) due to human herpesvirus 6 (HHV 6) infection. STUDY DESIGN: A case-control study of 20 febrile children with UPJ ulcers versus 26 febrile children without UPJ ulcers. These children were followed up for any development of ES and investigated for human herpesvirus 6 (HHV 6) as the causative agents of the febrile episodes. RESULTS: In this study, 20 out of 46 febrile children aged 3 months to 3 years with UPJ ulcers were virologically and/or serologically confirmed to be due to primary HHV 6 infection. The rest of the 26 children without ulcers did not have HHV 6 infection. Of the 20 children with UPJ ulcers, only 17 of the 19 children with adequate follow-up till subsidence of fever developed ES. None of the 26 children without UPJ ulcers developed ES. CONCLUSION: Statistically, there was a significant association of UPJ ulcers as an early sign of ES with a positive predictive value of 89.5% and negative predictive value of 100%. This finding also suggests that the presence of UPJ ulcers is a useful pathognomic clinical sign of symptomatic primary HHV 6 infection.

Pairings of a distinctive chamber with the aftereffect of wheel running produce conditioned place preference.

Wheel running reinforces behavior that precedes it. Also, wheel running can produce activity anorexia, a marked suppression of feeding in food-restricted rats. Some authors propose that the activity anorexia effect is produced by activation of the same reward system that mediates the reinforcing effect. One hypothesis is that such activation persists after wheel running stops and results in a rewarding aftereffect that suppresses feeding. Alternatively, such activation may give rise to an opponent process, an aversive aftereffect that suppresses feeding. The method of place conditioning was used to test whether the aftereffect of wheel running is rewarding or aversive. Food-deprived rats received pairings of a distinctive chamber with the aftereffect of wheel running. In Experiment 1, 2 h in a running wheel followed by 30 min in a distinctive chamber produced conditioned place preference. In Experiment 2, 22-22.5 h in a running wheel was followed by 30 min in the chamber and then a 60-min feeding test. Wheel running suppressed feeding and produced conditioned place preference. The conditioned place preference indicates that the aftereffect of wheel running is reinforcing rather than aversive. This finding supports the idea that the activation of the reward system persists after wheel running stops, thereby suppressing food intake.

Activity in the circular alley does not produce the activity anorexia syndrome in rats.

The activity anorexia syndrome is characterized by reduced food intake and body weight compared to control levels and increasing levels of physical activity. To induce it, food-restricted rats are confined in running wheels except during the daily meal. We tested whether activity in a flat circular alley also produces the activity anorexia syndrome. In Experiment 1, food-restricted rats were maintained in alleys, wheels, or home cages (control condition). In Experiment 2, they were maintained in alleys, wheels, novel cages, or home cages. The novel cage was added to control for the possibility that the alley might produce an anorectic effect simply because it was a new living space. The alley did not produce the activity anorexia syndrome whereas the wheel did. Although weight loss was greater in the alley than home-cage condition, the alley produced weak, inconsistent suppression of feeding. Moreover, the suppression produced by the alley may have stemmed simply from living in a novel environment. Finally, in contrast to wheel running, alley activity decreased over days. Alley activity, unlike wheel running, may not be reinforcing. Likely, a physical activity must be reinforcing to produce the activity anorexia syndrome. Implications for anorexia nervosa were discussed.

Chlordiazepoxide attenuates activity-induced anorexia and weight loss in rats.

In Experiment 1, the effect of repeated injections of 2.5, 5.0, or 10.0 mg/kg of chlordiazepoxide (CDP) on food intake and body weight was studied in rats on an activity anorexia (AA) regimen. For several days before CDP testing began, rats lived in activity wheels and had one 60-min meal per day. During CDP testing, this regimen continued except that each rat was injected with an appropriate dose of CDP or saline 30 min before each meal. CDP enhanced food intake; 5.0 mg/kg seemed most effective. However, the CDP-induced increase in eating did not noticeably stem weight loss. In Experiment 2, after several days of AA training, CDP (5.0 mg/kg) was tested under less severe conditions; food remained restricted, but access to the wheels was discontinued. Rats given CDP ate more and gained more weight than controls. These findings suggest that benzodiazepines such as CDP may help in treating anorexia nervosa and other anorectic conditions in humans.

Epidemiology and in vitro activity of antimycotics against candidal vaginal/skin/nail infections in Singapore.

BACKGROUND: Candidal infections of the skin/nails and vagina are very common worldwide. Various in vitro test systems are available to help to determine the antifungal activity of drugs. The minimum inhibitory concentration (MIC) is a standard measure of the in vitro potency of drugs against yeasts. METHODS: Vaginal smears and skin/nail scrapings of 50 consecutive patients with candidal vaginitis and 46 consecutive patients (28 women, 18 men) with cutaneous/nail candidosis were used in the study. Direct microscopy and culture from vaginal smears and skin scrapings were performed on all patients. The MICs were determined using the broth dilution method. RESULTS: For vaginal candidosis, the mean age of the patients was 28.2 years (range, 9-49 years). Candida albicans accounted for 58% of the isolates, C. glabrata for 32%, C. tropicalis for 6%, and C. parasilosis for 4%. At the MIC of < or = 4 mg/L, 65-95% of C. albicans, 66-94% of C. glabrata, 33-100% of C. tropicalis, and 0-50% of C. parasilosis were susceptible to the drugs tested (ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole). For cutaneous/nail candidosis, the mean age of the patients was 45 years (range, 19-82 years). C. albicans made up 59% of the isolates, C. parasilosis 20%, C. krusei 13%, C. glabrata 4%, and C. tropicalis 4%. At the MIC of < or = 4 mg/L, 59-96% of C. albicans, 100% of C. glabrata, 83-100% of C. krusei, 89-100% of C. parasilosis, and 100% of C. tropicalis were susceptible to the drugs tested (ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole). CONCLUSIONS: C. albicans is the most common Candida species causing cutaneous/nail and vaginal candidosis in Singapore. The in vitro antifungal activities of ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole are similar against the various Candida species. C. parasilosis in vaginal candidosis appears to be less susceptible. Here, itraconazole and amorolfine may be more effective.

Chlordiazepoxide counteracts activity-induced suppression of eating in rats.

Because benzodiazepines such as chlordiazepoxide increase food intake, the present experiments tested the effect of chlordiazepoxide on food intake in an animal model of anorexia nervosa, called activity anorexia (AA). To induce AA, rats (Rattus norvegicus) were maintained in activity wheels and restricted to a single 60-min feeding period each day. As previously found, this procedure suppressed food intake. After several days of this training, food intake was measured 30 min after the rats were injected with chlordiazepoxide (5 mg/kg) or saline. In 2 experiments, chlordiazepoxide counteracted the suppression of food intake produced by AA. Because benzodiazepines have been found to increase food intake in many mammalian species including primates, the present results suggest that benzodiazepines could be useful in the treatment of anorexia nervosa.