Epidemiology of transfusion-transmitted infections among multi-transfused patients in seven hospitals in Peru.

BACKGROUND: Transfusion-transmitted infections (TTIs) constitute a major health problem worldwide where routine screening of blood or blood products is improperly done, and where non-medical injecting medications and/or drug use are prevalent. Prevalence and risk factors vary by geographic location and by the specific TTI (including HIV-1, HBV, HCV and HTLV-I). OBJECTIVE: To determine the prevalence and risk factors associated with TTIs among a sample of multi-transfused adult patients in Peru. STUDY DESIGN: A cross-sectional multi-center study was conducted across seven major hospitals in Peru from February 2003 to September 2004. Self-reported behavior information (medical procedures, number of sexual partners, and drug use history) was analyzed, along with a review of exposure history from hospital medical records. Prevalences were calculated by TTI for different exposures, along with unadjusted and adjusted odds ratios for infection risk. RESULTS: Overall, 192 (54.7%) of 351 multi-transfused patients were found infected with one or more TTIs. Number of transfusion units, years of transfusion history (6 or more), and number of treatment facilities (2 or more) were associated with HCV infection. Hemodialysis history was a common risk factor associated with HBV, HCV and HTLV-I infection. HIV infection was associated only with total number of transfusion units received. CONCLUSIONS: High prevalences of HBV and HCV infection were found among Peruvian multi-transfused patients and were associated with a past history and number of blood transfusions, as well as with past hemodialysis procedures. TTIs continue to represent a significant public health problem in Peru. Continued vigilant attention to blood safety procedures, including universal screening and health care provider education, is recommended.

The interface between research and the diagnosis of an emerging tick-borne disease, human ehrlichiosis due to Ehrlichia chaffeensis.

Two new ehrlichial species that cause human disease have recently been identified: Ehrlichia chaffeensis and the currently unnamed agent of human granulocytic ehrlichiosis. Our objective was to review data on the clinical presentation, laboratory and epidemiological findings, therapy, and diagnostic procedures of patients with human ehrlichiosis due to E chaffeensis. From 1986 through 1994, 400 case patients were identified from 30 US states. Most patients had a nonspecific illness, characterized by fever and headache. Severe illness and death occurred, primarily in the elderly. Laboratory findings most commonly included leukopenia, thrombocytopenia, and elevated liver function test results. Antibody response was the basis for diagnosis, although polymerase chain reaction testing has been useful in research settings. Empirical treatment with tetracycline or its analogues should be begun as soon as possible after the onset of symptoms. Clinicians need to be alert for this illness when evaluating febrile patients whose history includes possible recent tick exposure.

Use of Bartonella antigens for serologic diagnosis of cat-scratch disease at a national referral center.

BACKGROUND: Bartonella henselae (formerly the genus Rochalimaea) has recently been isolated from patients with cat-scratch disease and their cats, and since September 1992 the Centers for Disease Control and Prevention has offered an indirect fluorescent antibody assay for Bartonella-specific antibody. METHODS: Physicians submitted serum samples from patients suspected of having cat-scratch disease or other Bartonella-associated illness and completed a questionnaire that recorded clinical information. Indirect fluorescent antibody assay was performed with the use of antigen derived from three Bartonella species: B henselae, Bartonella quintana, and Bartonella elizabethae. RESULTS: During 16 months, 3088 serum samples were received. The largest numbers of specimens and the highest percentages positive (titer, > or = 64) were observed in the fall and winter. Clinical histories of the first 600 patients for whom serum samples and completed information forms were received were examined in detail; seropositivity was significantly associated with cat contact, cat age of less than 1 year, cat scratch, presence of an inoculation papule, and regional adenopathy. Of 91 patients whose illness met a strict clinical definition of cat-scratch disease, 86 (95%) had titers of 64 or greater to either B henselae or B quintana. A fourfold rise or fall in titer was observed in 87 of 132 patients with paired serum samples. CONCLUSIONS: The indirect fluorescent antibody assay for Bartonella-specific antibody is sensitive for the diagnosis of cat-scratch disease. Redefinition of cat-scratch disease on the basis of cause and use of this assay as a diagnostic criterion is recommended.

Documentation of subtype C HIV Type 1 strains in Argentina, Paraguay, and Uruguay.

HIV subtypes B, F, and BF recombinants have been previously reported in South America. This report describes the presence of HIV-1 subtype C infection in the countries of Argentina, Uruguay, and Paraguay dating back to at least 1999. Surveillance for uncommon non-B/non-F subtype viruses circulating in South America has been conducted in samples obtained from nine countries. Peripheral blood mononuclear cells (PBMC), dried filter paper (FP), and fresh blood (FB) samples were collected from HIV-positive patients from Ecuador, Colombia, Venezuela, Peru, Chile, Bolivia, Argentina, Uruguay, and Paraguay. From a total of 2962 HIV seropositive samples examined during a 9-year period (1995-2003), only 11 (0.4%) were found to be infected with non-B/non-F HIV variants. Eight of these 11 strains were determined to be subtype C by heteroduplex mobility assay (HMA). Five of these 8 strains were further characterized by sequencing and phylogenetic analysis of the protease (Pro) and reverse transcriptase (RT) region of the genome and two were sequenced full length. One of the strains was found to be a unique BC recombinant. The spread of a third subtype of HIV, subtype C, should raise the question of its potential future role in the HIV epidemic in this region.

Cluster of five children with acute encephalopathy associated with cat-scratch disease in south Florida.

Between August 12 and September 27, 1994, five children in South Florida were hospitalized at a single hospital because of encephalopathy, presenting as status epilepticus, associated with cat-scratch disease (CSD). Diagnoses were confirmed by using an indirect fluorescent antibody test to detect antibody to Bartonella henselae, the causative agent of CSD. These cases represent the first cluster of CSD encephalopathy cases to be recognized in the United States. The patients lived within 7 miles of each other and all reported contact with pet or stray cats before developing regional lymphadenopathy and encephalopathy. All recovered fully. A high proportion of 124 cats from the local area were seropositive (62%) or bacteremic (22%). This study suggests that B. henselae can be associated with geographically focal clusters of CSD encephalitis and should be considered in the evaluation of children with acute encephalopathy.

Estimate of the risk of post transfusion hepatitis B in Jakarta, Indonesia.

The prevalences of hepatitis B surface antigen (HBsAg) and antibody to HBsAg (anti-HBs) were determined in blood donors and transfusion recipients in Jakarta, Indonesia. In blood donors the prevalence of HBsAg was 10% while anti-HBs was 43%. In transfusion recipients the prevalence of HBsAg and anti-HBs was 67%. The prevalence of susceptible recipients or those without detectable HBsAg or anti-HBs was 33%. Thus, the probability that a susceptible recipient would receive HBsAg from a blood donor was calculated at 3.3%. Published data from other studies were used to estimate the risk of clinical post transfusion hepatitis in Jakarta at between 0% and 2%.

Detection of eastern equine encephalomyelitis viral antigen in avian blood by enzyme immunoassay: a laboratory study.

An enzyme immunoassay (EIA) was evaluated for its efficacy at detecting eastern equine encephalomyelitis (EEE) virus in avian blood and brain specimens. Preliminary analysis of blood from experimentally infected house sparrows and naturally infected whooping cranes showed that EEE antigen could be detected with the EIA. Polyclonal mouse antibodies were selected for antigen capture, and rabbit antibodies were selected for antigen detection. Overnight antigen incubation increased sensitivity. The lower limit of EEE antigen detection was 10(3.5) TCID50/ml for a stock of virus. Sensitivity was 10% (2/20) for antigen detection in the blood of chicks inoculated with EEE virus less than 24 hr earlier. At 24 and 48 hr after infection, sensitivity was 100% (10/10). Sensitivity and specificity of antigen detection were excellent (100% for both) in house sparrows experimentally inoculated with EEE, Highlands J (HJ), western equine encephalomyelitis (WEE), or St. Louis encephalitis (SLE) virus and bled at 24 hr intervals. Cross-reactivity was observed, however, with high concentrations (10(5.5) TCID50/ml) of HJ virus. EEE antigen was detected in avian blood by the EIA after infectious virus had declined to undetectable levels. The EIA is a useful alternative to virus isolation in cell culture for diagnosis or detection of EEE virus infections in birds. The test has the advantages of being simple, rapid, and capable of detecting antigen in the absence of infectious virus.

Isolation of Batai virus (Bunyaviridae:Bunyavirus) from the blood of suspected malaria patients in Sudan.

From August through November 1988, 77,500 patients with fever presented to the municipal hospital and to eight government health centers in Kassala, a town of approximately 400,000 individuals in eastern Sudan. A diagnosis of malaria, based primarily on clinical presentation, was made in 14,395 individuals during this four-month period; fevers of unknown origin were diagnosed in 29 patients. A Bunyavirus that was antigenically similar or identical to Batai virus by complement fixation and plaque-reduction neutralization tests was recovered from two of 196 sera collected from patients with acute fever admitted to the municipal hospital in Kassala in October 1988. IgM antibody against this virus was detected by enzyme-linked immunosorbent assay in 7% of the sera from patients with acute fever tested and IgG antibody was detected in 61%.

A rapid dot immunoassay for the detection of serum antibodies to eastern equine encephalomyelitis and St. Louis encephalitis viruses in sentinel chickens.

A dot enzyme-linked immunosorbent assay utilizing a novel membrane, polyvinylidene difluoride, is described. This assay was developed for the rapid detection of serum antibodies to eastern equine encephalomyelitis virus and St. Louis encephalitis virus in sentinel chickens. Antigens were spot-filtered through the membrane. Membranes were dipped into small vials of sera. Antigen-antibody complexes were detected with enzyme-conjugated antiglobulin which, when exposed to substrate, produced a colored insoluble product. The antibody detection protocol was completed within 50 min and was compared with a standard plate enzyme immunoassay. Chickens were experimentally infected with eastern equine encephalomyelitis and St. Louis encephalitis and bled on a daily basis. The dot immunoassay correctly identified 99% (123/124) of the eastern equine encephalomyelitis virus and 100% (67/67) of the St. Louis encephalitis virus antisera. Sera from sentinel chicken flocks in Maryland were also assayed. These data indicate that the dot immunoassay should be considered as an alternative to current assays for the screening of sera for antibodies to virus antigens. This assay could easily be performed in the field and allows for the screening of antibodies to several different viruses in one test.

Short report: geographic distribution of different genetic types of Ehrlichia chaffeensis.

The 120-kD protein gene of Ehrlichia chaffeensis was used to characterize ehrlichial DNA from seven pools of adult Amblyomma americanum ticks. Ticks from Missouri, Kentucky, and North Carolina contained E. chaffeensis DNA of the Arkansas strain genotype. Ticks from North Carolina also contained ehrlichiae of the Sapulpa strain genotype, originally identified in Oklahoma.

Detection of murine typhus infected fleas with an enzyme-linked immunosorbent assay.

An enzyme-linked immunosorbent assay (ELISA) for the detection of Rickettsia typhi antigen in homogenates of pooled or individual laboratory infected fleas is described. The assay uses a double sandwich technique, employing a pool of monoclonal antibodies to capture the antigen and a hyperimmune rabbit serum for antigen detection. Using pools of R. typhi infected Xenopsylla cheopis, Ctenocephalides felis, and Leptopsylla segnis, the sensitivity of the ELISA was compared with direct fluorescent antibody examination of individual fleas for rickettsiae and with rickettsial titers determined by plaque enumeration on primary chicken embryo fibroblasts (PFU). Pooled samples with less than 4 PFU of viable rickettsiae gave ELISA results which were not significantly above background. Both ELISA OD and ELISA titer (last dilution giving an OD that was 2 SD above the control) of a 1:10 dilution of homogenate (4 fleas/ml) were linearly related to rickettsial titer up to 10(6.8) PFU/sample. Multiple freeze-thaws of pools of infected fleas led to a rapid loss of ELISA sensitivity. ELISA assays on single fleas demonstrated large individual variability in rickettsial content. This was independent of the number of days postinfectious feeding or the mean number of PFU/flea (10(1.7-6.9) found for pooled fleas in the same cohort. The sensitivity and ease of performance of ELISA should make it usable under field conditions.

Prevention of scrub typhus. Prophylactic administration of doxycycline in a randomized double blind trial.

We conducted a prospective randomized double blind study on the effects of doxycycline as a prophylactic antibiotic against scrub typhus. A total of 1,125 military subjects was followed for periods as long as 5 months of exposure in a hyperendemic focus in the Pescadores Islands of Taiwan. Oral 200 mg doses of doxycycline (Vibramycin) or placebo were given once each week throughout the trial. The incidence rate of scrub typhus in the placebo group was 2.5 times greater than that of the group taking doxycycline (P = 0.11). When subjects who failed to comply with scheduled administration of doxycycline were removed from the analysis, the incidence rate of scrub typhus in the control group was five times greater than that in the drug group (P = 0.04). The rates of infection with Rickettsia tsutsugamushi and of sick call reports were the same in experimental and control groups. The drug was well tolerated in pretrial tests and complaints were negligible during the conduct of the trial. Doxycycline appears to be an excellent antibiotic for the prevention of scrub typhus among personnel exposed to high risk of infection with R. tsutsugamushi.

Correlation of Culex tarsalis population indices with the incidence of St. Louis encephalitis and western equine encephalomyelitis in California.

Mosquito population indices from California for the period 1953-1973 were analyzed to determine their association with activity of St. Louis encephalitis (SLE) and western equine encephalomyelitis (WEE) viruses. Culex tarsalis female populations, as measured by New Jersey light trap indices (LTI), correlated positively with the incidence rates of encephalitis in humans, and were a reliable means of forecasting the years of highest incidence. The critical level of C. tarsalis in urban areas below which no human cases of SLE and WEE were detected was an LTI of 0.1. Critical urban levels of C. tarsalis associated with significant human SLE or WEE incidence ranged between LTIs of 6.4 (for rural mosquito abatement districts [MADs] with large resident human populations). Peaks in annual incidence of SLE and WEE in humans occurred during years when seasonal average C. tarsalis female populations in urban areas reached a LTI of 21. Peaks in weekly incidence of SLE and WEE were associated, respectively, with weekly LTIs of 21 and 81 in urban traps. Isolation rates of SLE virus from mosquito pools and transmission of the virus to enzootic hosts were highest when urban LTIs were between 10 and 19.9 and between 5 and 9.9, respectively. The WEE viral isolations and enzootic transmission rates were highest when LTIs in urban areas were 1-4.9.

National surveillance for Rocky Mountain spotted fever, 1981-1992: epidemiologic summary and evaluation of risk factors for fatal outcome.

Between 1981 and 1992, the Centers for Disease Control collected and summarized 9,223 cases of Rocky Mountain spotted fever (RMSF) reported from 46 states. Four states (North Carolina, Oklahoma, Tennessee, and South Carolina) accounted for 48% of the reports. The annual incidence per million U.S. population decreased from a high in 1981 of 5.2 to a low in 1992 of 2.0, primarily due to decreased incidence in the southeast. Case report forms were filed on 7,650 patients, of whom 4,217 had laboratory-confirmed RMSF. The age group with the highest incidence was those 5-9 years of age. Most cases (90.0%) occurred between April 1 and September 30 and included a history of tick attachment (59.6%). Reported symptoms included fever (94.0%), headache (86.2%), myalgia (82.5%), and rash (80.2%). The case-fatality ratio was 4.0%. Risk factors associated with death included older age, delay in treatment or no treatment, and treatment with chloramphenicol (compared with tetracycline); however, insufficient data existed to fully assess the confounding effect of severity of illness on antibiotic choice.

Amblyomma americanum: a potential vector of human ehrlichiosis.

Polymerase chain reaction primers specific for Ehrlichia chaffeensis were used to amplify DNA from extracts of pooled ticks. Amplification was performed on extracts from 140 pools (1,579 total ticks) consisting of three tick genera collected from five states. The characteristic 389-basepair product was observed after amplification of extracts from seven different pools of adult Amblyomma americanum (117 pools, 1,462 ticks), but not from pools of nymphs. No specific product was observed after amplification of 20 pools (105 ticks) of Dermacentor variabilis and three pools of Ixodes scapularis (12 ticks). Ehrlichia chaffeensis was present in A. americanum at a minimum frequency of > or = 0.48%, suggesting that A. americanum may be a vector of human ehrlichiosis.

Characteristics of Shigella sonnei infection of volunteers: signs, symptoms, immune responses, changes in selected cytokines and acute-phase substances.

Shigella sonnei infection resulting from oral administration of 500 colony-forming units was followed in 11 volunteers with the objective of studying the immune response and pathogenesis. Characterization of infection included recording of signs and symptoms, excretion of S. sonnei in stool, measurement of humoral tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1 beta), interferon-gamma (IFN-gamma), C-reactive protein, IL-2 receptor, soluble CD8, antibody-antigen complexes, and endotoxin. Measurements were also made of the immune response including lymphocytes secreting antibody to S. sonnei O antigen and serum antibody to this antigen. Six of the volunteers developed typical shigellosis with excretion of bacteria in stool and systemic signs and symptoms, three excreted bacteria but did not show illness, and two showed no evidence of infection or illness. Shigellosis was characterized by excretion in stool of S. sonnei beginning on average 1.3 days after ingestion. Excretion of S. sonnei (mean of time of the first positive cultures) was followed in sequence by the onset of increases in TNF-alpha (10 hr), liquid stools (14 hr), fever and dysentery (18 hr), IFN-gamma (22 hr), and C-reactive protein (34 hr). A S. sonnei-specific immune response was demonstrated somewhat later, between days 4 and 7 postinfection by antibody-secreting cells, and between days 7 and 14 postinfection by humoral antibody. Shigellosis was not associated with increased humoral IL-1 beta, endotoxin, or antigen-antibody complexes.

The epidemiology of hepatitis C virus antibody in Yemen.

A cross-sectional survey of 348 subjects without evidence of liver disease was conducted to investigate the prevalence and risk factors for hepatitis C virus antibody (anti-HCV) seropositivity in the Yemen Arab Republic. The mean age of study subjects was 28.7 years (range 3-80), and 61% were males. Using commercial enzyme-linked immunosorbent assays (ELISA), 6.0% (95% confidence interval [CI] 3.8-9.1) of subjects were anti-HCV-positive, 13.5% were hepatitis B surface antigen-positive (HBsAg-positive), and 51.4% were positive for at least one serologic marker of prior hepatitis B infection. Nine (2.6%; 95% CI 1.2-4.9) of the 21 ELISA-positive sera were confirmed to be anti-HCV positive by a recombinant immunoblot assay. Anti-HCV seropositivity was significantly associated with age (odds ratio [OR] 2.0 for each 10-year increase in age) and prior surgery (OR 10.1), but was not associated with a history of prior blood transfusion or markers of hepatitis B infection. These preliminary data suggest that hepatitis C may pose a substantial health threat in Yemen.

Fingerprinting of Ehrlichia species by repetitive element polymerase chain reaction.

To facilitate identification of ehrlichial pathogens, we developed a new technique based on fingerprints resulting from repetitive element polymerase chain reaction (rep-PCR). This technique uses consensus tRNA primers to generate amplification products that reflect distance polymorphisms between adjacent tRNA genes. Species-specific fingerprint patterns were obtained for seven Ehrlichia spp., as well as the unnamed causative agent of human granulocytotropic ehrlichiosis. Bands ranged in size from approximately 50 to 1,000 base pairs. Banding patterns varied depending on dilution of template DNA, with lower dilutions giving more complex banding patterns. These preliminary data indicate that repetitive-sequence-based PCR appears to be a useful technique for identifying ehrlichial organisms to the species, and perhaps the strain level. Compared with other conventional molecular-biologic methods, rep-PCR offers the advantages of ease of performance and rapid availability of results.

Distribution, diversity, and host specificity of Bartonella in rodents from the Southeastern United States.

A number of Bartonella isolates were obtained from seven species of rodents sampled from 12 geographic sites representing the major biotic communities of the southeastern United States. Bartonella were isolated from the blood of 42.2% of 279 tested rodents. The highest prevalence of infection typically occurred among the most commonly captured species in the rodent community. Four phylogenetic groups, uniting 14 genotypic variants of Bartonella, were identified by sequence analysis of the citrate synthase gene. The level of sequence homology between genotypic groups varied from 88.8% to 96.4%, and the degree of homology among variants within groups was > or = 97%. Cotton rats (Sigmodon hispidus) harbored up to three phylogenetic groups of Bartonella at a single site, and Bartonella of two phylogenetic groups were isolated from a single rodent. All the Bartonella isolated from three species of Peromyscus clustered in a single distinct phylogenetic group, suggesting some host specificity may occur. Mouse ascitic fluids produced in BALB/c mice inoculated with Bartonella of three phylogenetic groups demonstrated high indirect fluorescent antibody (IFA) titers to homologous antigens. However, use of eight Bartonella antigens in an IFA test with sera from 394 wild-caught rodents resulted in either little or extremely low titers of antibody.

Short report: surveillance of rickettsial infections in Indonesian military personnel during peace keeping operations in Cambodia.

Indonesian peacekeepers in Cambodia provided a unique study population to estimate the threat of rickettsial exposure to Rickettsia typhi (murine typhus), Orientia tsutsugamushi, (scrub typhus), and R. conorii (spotted fever) for the region. Prescreening prevalence measure showed a large proportion (36%) of soldiers with antibodies to R. typhi. Predeployment prevalence for antibodies to O. tsutsugamushi was 8%, with no evidence of background R. conorii infections. Actual seroconversions of R. typhi (3) and O. tsutsugamushi (1), attributed to exposure(s) in Cambodia, translated into annualized incidence rates of 24 and 8 per 1,000 per year, respectively. Surveillance of rickettsial infections and/or disease is particularly warranted in Cambodia with recent recognition of drug-resistant scrub typhus in neighboring Thailand.