Detection and Molecular Characterization of Zoonotic Poxviruses Circulating in the Amazon Region of Colombia, 2014

During 2014, cutaneous lesions were reported in dairy cattle and farmworkers in the Amazon Region of western Colombia. Samples from 6 patients were analyzed by serologic and PCR testing, and results demonstrated the presence of vaccinia virus and pseudocowpox virus. These findings highlight the need for increased poxvirus surveillance in Colombia.

The role of women's leadership and gender equity in leadership and health system strengthening

Gender equity is imperative to the attainment of healthy lives and wellbeing of all, and promoting gender equity in leadership in the health sector is an important part of this endeavour. This empirical research examines gender and leadership in the health sector, pooling learning from three complementary data sources: literature review, quantitative analysis of gender and leadership positions in global health organisations and qualitative life histories with health workers in Cambodia, Kenya and Zimbabwe. The findings highlight gender biases in leadership in global health, with women underrepresented. Gender roles, relations, norms and expectations shape progression and leadership at multiple levels. Increasing women's leadership within global health is an opportunity to further health system resilience and system responsiveness. We conclude with an agenda and tangible next steps of action for promoting women's leadership in health as a means to promote the global goals of achieving gender equity.

Evaluation of the GeneXpert for Human Monkeypox Diagnosis

Monkeypox virus (MPXV), a zoonotic orthopoxvirus (OPX), is endemic in the Democratic Republic of Congo (DRC). Currently, diagnostic assays for human monkeypox (MPX) focus on real-time quantitative polymerase chain reaction (PCR) assays, which are typically performed in sophisticated laboratory settings. Herein, we evaluated the accuracy and utility of a multiplex MPX assay using the GeneXpert platform, a portable rapid diagnostic device that may serve as a point-of-care test to diagnose infections in endemic areas. The multiplex MPX/OPX assay includes a MPX-specific PCR test, OPX-generic PCR test, and an internal control PCR test. In total, 164 diagnostic specimens (50 crusts and 114 vesicular swabs) were collected from suspected MPX cases in Tshuapa Province, DRC, under national surveillance guidelines. The specimens were tested with the GeneXpert MPX/OPX assay and an OPX PCR assay at the Institut National de Recherche Biomedicale (INRB) in Kinshasa. Aliquots of each specimen were tested in parallel with a MPX-specific PCR assay at the Centers for Disease Control and Prevention. The results of the MPX PCR were used as the gold standard for all analyses. The GeneXpert MPX/OPX assay performed at INRB had a sensitivity of 98.8% and specificity of 100%. The GeneXpert assay performed well with both crust and vesicle samples. The GeneXpert MPX/OPX test incorporates a simple methodology that performs well in both laboratory and field conditions, suggesting its viability as a diagnostic platform that may expand and expedite current MPX detection capabilities.

A rapid Orthopoxvirus purification protocol suitable for high-containment laboratories

Virus purification in a high-containment setting provides unique challenges due to barrier precautions and operational safety approaches that are not necessary in lower biosafety level (BSL) 2 environments. The need for high risk group pathogen diagnostic assay development, anti-viral research, pathogenesis and vaccine efficacy research necessitates work in BSL-3 and BSL-4 labs with infectious agents. When this work is performed in accordance with BSL-4 practices, modifications are often required in standard protocols. Classical virus purification techniques are difficult to execute in a BSL-3 or BSL-4 laboratory because of the work practices used in these environments. Orthopoxviruses are a family of viruses that, in some cases, requires work in a high-containment laboratory and due to size do not lend themselves to simpler purification methods. Current CDC purification techniques of orthopoxviruses uses 1,1,2-trichlorotrifluoroethane, commonly known as Genetron^®. Genetron^® is a chlorofluorocarbon (CFC) that has been shown to be detrimental to the ozone and has been phased out and the limited amount of product makes it no longer a feasible option for poxvirus purification purposes. Here we demonstrate a new Orthopoxvirus purification method that is suitable for high-containment laboratories and produces virus that is not only comparable to previous purification methods, but improves on purity and yield.

A Pan-Lyssavirus Taqman Real-Time RT-PCR Assay for the Detection of Highly Variable Rabies virus and Other Lyssaviruses

Rabies, resulting from infection by Rabies virus (RABV) and related lyssaviruses, is one of the most deadly zoonotic diseases and is responsible for up to 70,000 estimated human deaths worldwide each year. Rapid and accurate laboratory diagnosis of rabies is essential for timely administration of post-exposure prophylaxis in humans and control of the disease in animals. Currently, only the direct fluorescent antibody (DFA) test is recommended for routine rabies diagnosis. Reverse-transcription polymerase chain reaction (RT-PCR) based diagnostic methods have been widely adapted for the diagnosis of other viral pathogens, but there is currently no widely accepted rapid real-time RT-PCR assay for the detection of all lyssaviruses. In this study, we demonstrate the validation of a newly developed multiplex real-time RT-PCR assay named LN34, which uses a combination of degenerate primers and probes along with probe modifications to achieve superior coverage of the Lyssavirus genus while maintaining sensitivity and specificity. The primers and probes of the LN34 assay target the highly conserved non-coding leader region and part of the nucleoprotein (N) coding sequence of the Lyssavirus genome to maintain assay robustness. The probes were further modified by locked nucleotides to increase their melting temperature to meet the requirements for an optimal real-time RT-PCR assay. The LN34 assay was able to detect all RABV variants and other lyssaviruses in a validation panel that included representative RABV isolates from most regions of the world as well as representatives of 13 additional Lyssavirus species. The LN34 assay was successfully used for both ante-mortem and post-mortem diagnosis of over 200 clinical samples as well as field derived surveillance samples. This assay represents a major improvement over previously published rabies specific RT-PCR and real-time RT-PCR assays because of its ability to universally detect RABV and other lyssaviruses, its high throughput capability and its simplicity of use, which can be quickly adapted in a laboratory to enhance the capacity of rabies molecular diagnostics. The LN34 assay provides an alternative approach for rabies diagnostics, especially in rural areas and rabies endemic regions that lack the conditions and broad experience required to run the standard DFA assay.

Rabies is a preventable disease–but is still responsible for approximately 70,000 human deaths worldwide each year. The majority of human deaths occur in Asia and Africa where there is a lack of diagnostic resources and expertise, making it difficult to develop effective prevention and control strategies. In recent years, several real-time RT-PCR based diagnostic assays have been introduced to many developing countries in an effort to control the H1N1 pandemic flu, Ebola outbreak, and other tropical viral infections. In an effort to further improve rabies diagnostics, we developed a pan-lyssavirus Taqman real-time RT-PCR assay called LN34 for the detection of all known RABV variants and other lyssavirus species. The LN34 assay uses a combination of degenerate nucleotides, multiplex primers and probes, and unique probe modifications to achieve superior sensitivity and specificity compared to previously published RT-PCR based rabies diagnostics. Equally important, the LN34 assay is simple to set up, high throughput, combines multiple standard controls and can be used directly in widely available real-time RT-PCR systems. The LN34 assay was validated using a broad and comprehensive panel of highly diverse RABV variants and other lyssaviruses. A validated universal rabies diagnostic assay will be important in regions where RABV and other lyssaviruses co-circulate and for establishing a widely accepted diagnostic protocol. Over 200 clinical samples (including ante-mortem, post-mortem, and field derived samples) were tested with the LN34 assay, and the assay achieved 100% diagnostic sensitivity and specificity in our laboratory. Over 300 published genome sequences from representatives of RABV and other lyssaviruses were found to contain the conserved LN34 primer and probe targeting sites in an in silico analysis. We are expanding the validation of the LN34 assay to multiple domestic and international laboratories and expect the LN34 assay will drastically improve rabies diagnostic capacities globally.

Adolescent and young adult cancer: principles of care

Adolescents and young adults (ayas) with cancer in active treatment face a number of barriers to optimal care. In the present article, we focus on the 3 critical domains of care for ayas-medical, psychosocial, and research-and how changes to the system could overcome barriers. We summarize the current literature, outline recommended principles of care, raise awareness of barriers to optimal care, and suggest specific changes to the system to overcome those barriers in the Canadian context. Many of the recommendations can nevertheless be applied universally. These recommendations are endorsed by the Canadian Task Force on Adolescents and Young Adults with Cancer and build on outcomes from two international workshops held by that group.

Human Monkeypox in the Kivus, a Conflict Region of the Democratic Republic of the Congo

Monkeypox (MPX) is a zoonotic Orthopoxvirus infection endemic in central and western Africa. Human MPX cases occur in the central and northern regions of the Democratic Republic of the Congo (DRC), and this is the first report of confirmed MPX cases in the forested areas of North and South Kivu Provinces, with a detailed epidemiological investigation for one case. The location of each case is within areas predicted to be suitable for MPX virus transmission based on an ecological niche model. Phylogenetic analysis places these viruses in the Congo Basin clade.

Laboratory-acquired vaccinia virus infection in a recently immunized person--Massachusetts, 2013

On November 26, 2013, the CDC poxvirus laboratory was notified by the Boston Public Health Commission (BPHC) of an inadvertent inoculation of a recently vaccinated (ACAM2000 smallpox vaccine) laboratory worker with wild type vaccinia virus (VACV) Western Reserve. A joint investigation by CDC and BPHC confirmed orthopoxvirus infection in the worker, who had reported a needle stick in his thumb while inoculating a mouse with VACV. He experienced a non-tender, red rash on his arm, diagnosed at a local emergency department as cellulitis. He subsequently developed a necrotic lesion on his thumb, diagnosed as VACV infection. Three weeks after the injury, the thumb lesion was surgically debrided and at 2 months post-injury, the skin lesion had resolved. The investigation confirmed that the infection was the first reported VACV infection in the United States in a laboratory worker vaccinated according to the Advisory Committee on Immunization Practices (ACIP) recommendations. The incident prompted the academic institution to outline biosafety measures for working with biologic agents, such as biosafety training of laboratory personnel, vaccination (if appropriate), and steps in incident reporting. Though vaccination has been shown to be an effective measure in protecting personnel in the laboratory setting, this case report underscores the importance of proper safety measures and incident reporting.

Novel poxvirus infection in 2 patients from the United States

BACKGROUND

Some human poxvirus infections can be acquired through zoonotic transmission. We report a previously unknown poxvirus infection in 2 patients, 1 of whom was immunocompromised; both patients had known equine contact.

METHODS

The patients were interviewed and clinical information was abstracted from the patients' medical files. Biopsies of the skin lesions were collected from both patients for histopathology, immunohistochemistry, and transmission electron microscopy analysis. Oral and skin swabs were collected from animals with frequent contact with the patients, and environmental sampling including rodent trapping was performed on the farm where the immunosuppressed patient was employed. "Pan-pox and high Guanine-cytosine" polymerase chain reaction assays were performed on patient, animal, and environmental isolates. Amplicon sequences of the viral DNA were used for agent identification and phylogenetic analysis.

RESULTS

Specimens from both human cases revealed a novel poxvirus. The agent shares 88% similarity to viruses in the Parapoxvirus genus and 78% to those in the Molluscipoxvirus genus but is sufficiently divergent to resist classification as either. All animal and environmental specimens were negative for poxvirus and both patients had complete resolution of lesions.

CONCLUSIONS

This report serves as a reminder that poxviruses should be considered in cutaneous human infections, especially in individuals with known barnyard exposures. The clinical course of the patients was similar to that of parapoxvirus infections, and the source of this virus is currently unknown but is presumed to be zoonotic. This report also demonstrates the importance of a comprehensive approach to diagnosis of human infections caused by previously unknown pathogens.

Poxvirus viability and signatures in historical relics

Although it has been >30 years since the eradication of smallpox, the unearthing of well-preserved tissue material in which the virus may reside has called into question the viability of variola virus decades or centuries after its original occurrence. Experimental data to address the long-term stability and viability of the virus are limited. There are several instances of well-preserved corpses and tissues that have been examined for poxvirus viability and viral DNA. These historical specimens cause concern for potential exposures, and each situation should be approached cautiously and independently with the available information. Nevertheless, these specimens provide information on the history of a major disease and vaccination against it.

Poxvirus viability and signatures in historical relics

Although it has been >30 years since the eradication of smallpox, the unearthing of well-preserved tissue material in which the virus may reside has called into question the viability of variola virus decades or centuries after its original occurrence. Experimental data to address the long-term stability and viability of the virus are limited. There are several instances of well-preserved corpses and tissues that have been examined for poxvirus viability and viral DNA. These historical specimens cause concern for potential exposures, and each situation should be approached cautiously and independently with the available information. Nevertheless, these specimens provide information on the history of a major disease and vaccination against it.

Novel poxvirus in big brown bats, northwestern United States

A wildlife hospital and rehabilitation center in northwestern United States received several big brown bats with necrosuppurative osteomyelitis in multiple joints. Wing and joint tissues were positive by PCR for poxvirus. Thin-section electron microscopy showed poxvirus particles within A-type inclusions. Phylogenetic comparison supports establishment of a new genus of Poxviridae.

Development and validation of a portable platform for deploying decision-support algorithms in prehospital settings

BACKGROUND

Advanced decision-support capabilities for prehospital trauma care may prove effective at improving patient care. Such functionality would be possible if an analysis platform were connected to a transport vital-signs monitor. In practice, there are technical challenges to implementing such a system. Not only must each individual component be reliable, but, in addition, the connectivity between components must be reliable.

OBJECTIVE

We describe the development, validation, and deployment of the Automated Processing of Physiologic Registry for Assessment of Injury Severity (APPRAISE) platform, intended to serve as a test bed to help evaluate the performance of decision-support algorithms in a prehospital environment.

METHODS

We describe the hardware selected and the software implemented, and the procedures used for laboratory and field testing.

RESULTS

The APPRAISE platform met performance goals in both laboratory testing (using a vital-sign data simulator) and initial field testing. After its field testing, the platform has been in use on Boston MedFlight air ambulances since February of 2010.

CONCLUSION

These experiences may prove informative to other technology developers and to healthcare stakeholders seeking to invest in connected electronic systems for prehospital as well as in-hospital use. Our experiences illustrate two sets of important questions: are the individual components reliable (e.g., physical integrity, power, core functionality, and end-user interaction) and is the connectivity between components reliable (e.g., communication protocols and the metadata necessary for data interpretation)? While all potential operational issues cannot be fully anticipated and eliminated during development, thoughtful design and phased testing steps can reduce, if not eliminate, technical surprises.

Detection of human monkeypox in the Republic of the Congo following intensive community education

Monkeypox is an acute viral infection with a clinical course resembling smallpox. It is endemic in northern and central Democratic Republic of the Congo (DRC), but it is reported only sporadically in neighboring Republic of the Congo (ROC). In October 2009, interethnic violence in northwestern DRC precipitated the movement of refugees across the Ubangi River into ROC. The influx of refugees into ROC heightened concerns about monkeypox in the area, because of the possibility that the virus could be imported, or that incidence could increase caused by food insecurity and over reliance on bush meat. As part of a broad-based campaign to improve health standards in refugee settlement areas, the United Nations International Children's Emergency Fund (UNICEF) sponsored a program of intensive community education that included modules on monkeypox recognition and prevention. In the 6 months immediately following the outreach, 10 suspected cases of monkeypox were reported to health authorities. Laboratory testing confirmed monkeypox virus infection in two individuals, one of whom was part of a cluster of four suspected cases identified retrospectively. Anecdotes collected at the time of case reporting suggest that the outreach campaign contributed to detection of suspected cases of monkeypox.

Impact of glucose and acetate on the characteristics of the platelet storage lesion in platelets suspended in additive solutions with minimal plasma

BACKGROUND AND OBJECTIVES

Glucose and acetate have been proposed to be required elements in platelet storage media. This study investigated the role of these compounds on the varied elements that comprise the platelet storage lesion.

MATERIALS AND METHODS

For each replicate, four pooled and split ABO group-specific buffy coat-derived platelet concentrates were suspended in an in-house additive solution with minimal plasma and varying final concentrations of acetate or glucose. Units were sampled on days 2, 3, 6, 8 and 10 and tested for markers of platelet morphology, activation, function, metabolism and indicators of cell death.

RESULTS

The absence of glucose was associated with a decrease in ATP, falling to a mean of 1·1 ± 0·1 μmol/10(11) plts in units with no added glucose compared with 4·2 ± 0·6 μmol/10(11) plts (P < 0·001) in units with 30 mm glucose. As glucose became depleted, the decrease in ATP to levels below 3 μmol/10(11) plts was associated with an increase in both annexin V binding and intracellular free calcium. In units lacking exogenous acetate, ATP levels on day 10 were 5·2 ± 1·5 μmol/10(11) plts compared with 2·7 ± 0·9 μmol/10(11) plts in units with 56 mm acetate (P = 0·006). Higher concentrations of exogenous acetate were associated with a lower hypotonic shock response and higher surface expression of CD62P suggestive of a dose dependency.

CONCLUSION

Under current physical storage conditions, glucose appears necessary for the maintenance of platelets stored as concentrates in minimal volumes of plasma. The addition of acetate was associated with increased platelet activation and reduced ATP levels.

Investigation of the first laboratory-acquired human cowpox virus infection in the United States

BACKGROUND

Cowpox virus is an Orthopoxvirus that can cause infections in humans and a variety of animals. Infections occur in Eurasia; infections in humans and animals have not been reported in the United States. This report describes the occurrence of the first known human case of laboratory-acquired cowpox virus infection in the United States and the ensuing investigation.

METHODS

The patient and laboratory personnel were interviewed, and laboratory activities were reviewed. Real-time polymerase chain reaction (PCR) and serologic assays were used to test the patient's specimens. PCR assays were used to test specimens obtained during the investigation.

RESULTS

A specimen from the patient's lesion tested positive for cowpox virus DNA. Genome sequencing revealed a recombinant region consistent with a strain of cowpox virus stored in the research laboratory's freezer. Cowpox virus contamination was detected in 6 additional laboratory stocks of viruses. Orthopoxvirus DNA was present in 3 of 20 environmental swabs taken from laboratory surfaces.

CONCLUSIONS

The handling of contaminated reagents or contact with contaminated surfaces was likely the mode of transmission. Delays in recognition and diagnosis of this infection in a laboratory researcher underscore the importance of a thorough patient history-including occupational information-and laboratory testing in facilitating a prompt investigation and application of control and remediation measures.

Secondary and tertiary transmission of vaccinia virus from US military service member

During February and March 2010, the New York State Department of Health investigated secondary and tertiary vaccinia contact transmission from a military vaccinee to 4 close contacts. Identification of these cases underscores the need for strict adherence to postvaccination infection control guidance to avoid transmission of the live virus.

Real-time PCR assays for the specific detection of monkeypox virus West African and Congo Basin strain DNA

Orthopoxvirus monkeypox (MPXV) forms two distinct clades: the MPXV Congo Basin clade viruses are endemic in the Congo Basin, human illness typically presents with symptoms similar to discrete, ordinary smallpox and has a case fatality rate of approximately 10% in unvaccinated populations; the MPXV West African clade viruses have been isolated in West Africa and appear to cause a less severe, and less inter-human transmissible disease. Recently, monkeypox outbreaks were reported in US and Sudan caused by MPXV West African and Congo Basin strains respectively. These events demonstrated the ability and trend of the virus to exploit new hosts and emerge globally; it also emphasizes the need for the diagnosis of MPXV, especially the ability to distinguish between Congo Basin and West African monkeypox strains. In this study, three new real-time PCR assays based on TaqMan probe technology were reported: the MPXV West African specific, Congo Basin strain specific and MPXV generic assays. The new assays demonstrated good specificity and sensitivity in the validation study with multiple platforms and various PCR reagent kits, and will improve the rapid detection and differentiation of monkeypox infections from other rash illness.

Reaching every district (RED) approach to strengthen routine immunization services: evaluation in the African region, 2005

BACKGROUND

This evaluation was undertaken in 2005, in the African region, to better understand the reaching every district (RED) implementation process that provides a framework for strengthening immunization services at the district level.

METHODS

In June 2005, a convenience sample of five countries was selected to evaluate the implementation of RED. Evaluation teams consisting of key partners conducted site visits to the national, district and health facility levels using standardized qualitative questionnaires.

RESULTS

RED was implemented in a similar manner in all five countries, i.e. starting with training and micro-planning. All RED components were implemented to some degree in the countries. Common implementation factors included development of plans, expanding outreach services (defined as services provided in sites outside fixed immunization sites), planning of supervisory visits and efforts to link with communities and utilize community volunteers. Monitoring tools such as wall charts and maps were observed and reportedly used.

CONCLUSIONS

Evaluation of the RED implementation process provided evidence of improvement in delivery of routine immunization services. The RED framework should continue to be used to strengthen the immunization delivery system to meet continuing new demands, such as the introduction of new vaccines and integrated delivery of other child survival interventions.

The effect of bipolar I disorder and major depressive disorder on workforce function

This investigation was undertaken to explore and compare the effect of bipolar I disorder (BD) and major depressive disorder (MDD) on workforce function. The data for this analysis were procured from the Canadian Community Health Survey (CCHS 1.2). The sample consisted of 20 747 individuals (≥ 18 years old and currently working); the proportions screening positive for lifetime BD and MDD were 2.4% and 11.2%, respectively. Individuals with BD or MDD had a signifi cantly lower mean annual income, compared to people without these disorders. Individuals with BD had a signifi cantly lower annual income when compared to MDD (p $lt; 0.05). Results from a multiple logistic regression also indicate that employed individuals with BD had greater odds of reporting one or more mental health disability days in the past two weeks, compared with those with MDD (OR = 1.6; 95% CI = 1.0 to 2.6). Currently employed individuals with BD had lower odds of “good job security” relative to those with MDD (OR = 0.6 95% CI = 0.5 to 0.9). The data herein underscore the pernicious effect of BD on workforce function, and suggest that opportunistic screening for BD in all individuals utilizing employment assistance programs for depression might be warranted.