Respiratory viral infections in the elderly

Discovery and development of INNA-051, a TLR2/6 agonist for the prevention of complications resulting from viral respiratory infections

Viral respiratory infection is associated with significant morbidity and mortality. The diversity of viruses implicated, coupled with their propensity for mutation, ignited an interest in host-directed antiviral therapies effective across a wide range of viral variants. Toll-like receptors (TLRs) are potential targets for the development of broad-spectrum antivirals given their central role in host immune defenses. Synthetic agonists of TLRs have been shown to boost protective innate immune responses against respiratory viruses. However, clinical success was hindered by short duration of benefit and/or induction of systemic adverse effects. INNA-051, a TLR2/6 agonist, is in development as an intranasal innate immune enhancer for prophylactic treatment in individuals at risk of complications resulting from respiratory viral infections. In vivo animal studies demonstrated the efficacy as prophylaxis against multiple viruses including SARS-CoV-2, influenza, and rhinovirus. Early clinical trials demonstrated an acceptable safety and tolerability profile. Intranasal delivery to the primary site of infection in humans induced a local innate host defense response characterized by innate immune cell infiltration into the nasal epithelium and activation and antiviral response genes. Taken together, the preclinical and clinical data on INNA-051 support further investigation of its use in community infection settings.

Co-Infection Rates between SARS-CoV-2 and RSV in Oropharyngeal, Nasopharyngeal Aspirate and Saliva Samples of COVID-19 Patients, Shiraz, South of Iran

Statement of the Problem

Determining the prevalence of respiratory viruses' coinfection with coronavirus disease 2019 (COVID-19) is essential to defining its true clinical influence.

Purpose

This study aimed to evaluate co-infection rates between severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) and respiratory syncytial virus (RSV) in infected patients in Shiraz, south of Iran.

Materials and Method

In a cross-sectional descriptive study, oropharyngeal, nasopharyngeal aspirate (NPA), and saliva samples of 50 COVID-19 patients who were referred to Ali-Asghar hospital (Shiraz, Iran) from March to August 2020, were collected. A control group consisted of age and sex-matched healthy participants. The nasopharyngeal and oropharyngeal aspirates were collected by sterile swabs. All cases were hospitalized, and all SARS-CoV-2 patients had a fever and respiratory symptoms. The samples were packed in a vial with 1 mL of transport medium and transported to the Valfagre specialty laboratory, where they were tested for RSV using a real-time polymerase chain reaction (PCR).

Results

100 nasopharyngeal/oropharyngeal aspirates and saliva samples including 50 healthy controls (24 females, 26 males) and 50 COVID-19 patients' samples (27 males and 23 females) were studied. There was no significant difference regarding age as well as gender between both groups (p> 0.05). None of the healthy subjects was infected with RSV; however, 5(10%) patients from COVID-19 group were infected with the RSV virus. Chi-square test did not show a significant difference between RSV infection in COVID-19 patients and healthy subjects.

Conclusion

The outcome of present research showed that concurrent RSV with COVID 19 infection might be seen in hospitalized patients in Shiraz Southwest of Iran. For more reliable findings, further research on bigger populations, including more pathogens in several places around the country, and considering the severity of symptoms is required.

Sex Differences in Respiratory Viral Pathogenesis and Treatments

Biological sex affects the outcome of diverse respiratory viral infections. The pathogenesis of respiratory infections caused by viruses ranging from respiratory syncytial virus to influenza viruses and severe acute respiratory syndrome coronavirus 2 differs between the sexes across the life course. Generally, males are more susceptible to severe outcomes from respiratory viral infections at younger and older ages. During reproductive years (i.e., after puberty and prior to menopause), females are often at greater risk than males for severe outcomes. Pregnancy and biological sex affect the pathogenesis of respiratory viral infections. In addition to sex differences in the pathogenesis of disease, there are consistent sex differences in responses to treatments, with females often developing greater immune responses but experiencing more adverse reactions than males. Animal models provide mechanistic insights into the causes of sex differences in respiratory virus pathogenesis and treatment outcomes, where available. Expected final online publication date for the Annual Review of Virology, Volume 8 is September 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Intranasal Vaccine Delivery Technology for Respiratory Tract Disease Application with a Special Emphasis on Pneumococcal Disease

This mini-review will cover recent trends in intranasal (IN) vaccine delivery as it relates to applications for respiratory tract diseases. The logic and rationale for IN vaccine delivery will be compared to methods and applications accompanying this particular administration route. In addition, we will focus extended discussion on the potential role of IN vaccination in the context of respiratory tract diseases, with a special emphasis on pneumococcal disease. Here, elements of this disease, including its prevalence and impact upon the elderly population, will be viewed from the standpoint of improving health outcomes through vaccine design and delivery technology and how IN administration can play a role in such efforts.

Lower respiratory tract infection in the community: associations between viral aetiology and illness course

OBJECTIVES

This study determined associations between respiratory viruses and subsequent illness course in primary care adult patients presenting with acute cough and/or suspected lower respiratory tract infection.

METHODS

A prospective European primary care study recruited adults with symptoms of lower respiratory tract infection between November 2007 and April 2010. Real-time in-house polymerase chain reaction (PCR) was performed to test for six common respiratory viruses. In this secondary analysis, symptom severity (scored 1 = no problem, 2 = mild, 3 = moderate, 4 = severe) and symptom duration were compared between groups with different viral aetiologies using regression and Cox proportional hazard models, respectively. Additionally, associations between baseline viral load (cycle threshold (Ct) value) and illness course were assessed.

RESULTS

The PCR tested positive for a common respiratory virus in 1354 of the 2957 (45.8%) included patients. The overall mean symptom score at presentation was 2.09 (95% confidence interval (CI) 2.07-2.11) and the median duration until resolution of moderately bad or severe symptoms was 8.70 days (interquartile range 4.50-11.00). Patients with influenza virus, human metapneumovirus (hMPV), respiratory syncytial virus (RSV), coronavirus (CoV) or rhinovirus had a significantly higher symptom score than patients with no virus isolated (0.07-0.25 points or 2.3-8.3% higher symptom score). Time to symptom resolution was longer in RSV infections (adjusted hazard ratio (AHR) 0.80, 95% CI 0.65-0.96) and hMPV infections (AHR 0.77, 95% CI 0.62-0.94) than in infections with no virus isolated. Overall, baseline viral load was associated with symptom severity (difference 0.11, 95% CI 0.06-0.16 per 10 cycles decrease in Ct value), but not with symptom duration.

CONCLUSIONS

In healthy, working adults from the general community presenting at the general practitioner with acute cough and/or suspected lower respiratory tract infection other than influenza impose an illness burden comparable to influenza. Hence, the public health focus for viral respiratory tract infections should be broadened.

Community-Acquired Respiratory Viruses in Transplant Patients: Diversity, Impact, Unmet Clinical Needs

Patients undergoing solid-organ transplantation (SOT) or allogeneic hematopoietic cell transplantation (HCT) are at increased risk for infectious complications. Community-acquired respiratory viruses (CARVs) pose a particular challenge due to the frequent exposure pre-, peri-, and posttransplantation. Although influenza A and B viruses have a top priority regarding prevention and treatment, recent molecular diagnostic tests detecting an array of other CARVs in real time have dramatically expanded our knowledge about the epidemiology, diversity, and impact of CARV infections in the general population and in allogeneic HCT and SOT patients. These data have demonstrated that non-influenza CARVs independently contribute to morbidity and mortality of transplant patients. However, effective vaccination and antiviral treatment is only emerging for non-influenza CARVs, placing emphasis on infection control and supportive measures. Here, we review the current knowledge about CARVs in SOT and allogeneic HCT patients to better define the magnitude of this unmet clinical need and to discuss some of the lessons learned from human influenza virus, respiratory syncytial virus, parainfluenzavirus, rhinovirus, coronavirus, adenovirus, and bocavirus regarding diagnosis, prevention, and treatment.

Respiratory tract virus infections in the elderly with pneumonia

BACKGROUND

In children suffering from severe lower airway illnesses, respiratory virus detection has given good prognostic information, but such reports in the elderly are scarce. Therefore, our aim was to study whether the detection of nasopharyngeal viral pathogens and conventional inflammatory markers in the frail elderly correlate to the presence, signs and symptoms or prognosis of radiographically-verified pneumonia.

METHODS

Consecutive episodes of hospital care of patients 65 years and older with respiratory symptoms (N = 382) were prospectively studied as a cohort. Standard clinical questionnaire was filled by the study physician. Laboratory analyses included PCR diagnostics of nasopharyngeal swab samples for 14 respiratory viruses, C-reactive protein (CRP) and white blood cell count (WBC). Chest radiographs were systematically analysed by a study radiologist. The length of hospital stay, hospital revisit and death at ward were used as clinical endpoints.

RESULTS

Median age of the patients was 83 years (range 76-90). Pneumonia was diagnosed in 112/382 (29%) of the studied episodes. One or more respiratory viruses were detected in 141/382 (37%) episodes and in 34/112 (30%) episodes also diagnosed with pneumonia. Pneumonia was associated with a WBC over 15 × 10⁹/L (P = .006) and a CRP value over 80 mg/l (P < .05). A virus was detected in 30% of pneumonia episodes and in 40% of non-pneumonia episodes, but this difference was not significant (P = 0.09). The presence of a respiratory virus was associated with fewer revisits to the hospital (P < .05), whereas a CRP value over 100 mg/l was associated with death during hospital stay (P < .05). Respiratory virus detections did not correlate to WBC or CRP values, signs and symptoms or prognosis of radiographically-verified pneumonia episodes.

CONCLUSION

Among the elderly with respiratory symptoms, respiratory virus detection was not associated with an increased risk of pneumonia or with a more severe clinical course of the illness. CRP and WBC remain important indicators of pneumonia, and according to our findings, pneumonia should be treated as a bacterial disease regardless of the virus findings. Our data does not support routine virus diagnostics for the elderly patients with pneumonia outside the epidemic seasons.

Synthesis of three triterpene series and their activity against respiratory syncytial virus

The human respiratory syncytial virus (hRSV) is a leading cause of hospitalization due to acute lower respiratory infection especially in infants and young children, sometimes causing fatal cases. The monoclonal antibody palivizumab is one of the available options for preventing this virus, and at the moment there are several hRSV vaccine trials underway. Unfortunately, the only drug option to treat hRSV infection is ribavirin, which can be used in severe high-risk cases. For this reason, new medicines are needed and, in this context, the triterpenes and their derivatives are promising alternatives, since many of them have shown important antiviral activity, such as bevirimat. Therefore, we report three series of triterpene (betulin (BE), betulinic acid (BA), and ursolic acid (UA)) derivatives tested against hRSV. The derivatives were synthesized by using commercial anhydrides in an easy and inexpensive step reaction. For the antiviral assay, A549 cells were infected by hRSV and after 96 h of compound or ribavirin (positive control) treatment, the cell viability was tested by MTT assay. DMSO, non-infected cells and infected cells without treatment were used as negative control. The triterpene esterification at the hydroxyl group resulted in 17 derivatives. The 3,28-di-O-acetylbetulin derivative (1a) showed the best results for cell viability, and real-time PCR amplification was performed for 1a treatment. Remarkably, one new anti-hRSV prototype was obtained through an easy synthesis of BE, which shall represent an alternative for a new lead compound for anti-hRSV therapy.

Clinical Evaluation and Symptoms of Chemosensory Impairment: One Thousand Consecutive Cases from the Nasal Dysfunction Clinic in San Diego

Background

The aim of this study was to measure olfactory impairment in patients with various etiologies using symptom ratings and psychophysical measures of olfactory function.

Methods

We performed a cross-sectional, population-based study at the Nasal Dysfunction Clinic of the University of California, San Diego (UCSD), Medical Center. One thousand consecutive patients presented to the UCSD Nasal Dysfunction Clinic for evaluation of chemosensory dysfunction. Olfactory impairment was assessed by odor threshold and odor identification and symptom scores were assessed by self-report.

Results

The degree of olfactory impairment was driven by diagnostic category, age, and gender. Postviral disturbance was more prevalent in women and among elderly people. Elderly people and patients under 20 years of age showed the highest incidence of head trauma. Overall, older patients had poorer thresholds. Men showed higher prevalence of olfactory loss secondary to inflammation and toxin exposure. Patients with inflammation scored better than patients with other diagnoses (i.e., congenital, head trauma, postviral, toxin exposure, and miscellaneous causes). Patients with congenital etiologies and head trauma had the poorest scores. Symptom ratings were significantly different depending on diagnostic category, age, and gender. Patients with inflammation rated the majority of symptoms as most bothersome. Patients with postviral diagnoses were most likely to report parosmias. Patients with head trauma rated taste and smell loss as significantly more severe than other patients.

Conclusion

Evaluation of 1000 patients at the UCSD Nasal Dysfunction Clinic in San Diego revealed differential olfactory impairment and differential symptom complaints based on diagnostic category, age, and gender.

Volatile oils: Potential agents for the treatment of respiratory infections

Due to presence of secondary bioactive metabolites, natural compounds are considered a major source of new active molecules that can be developed as new drugs. Infectious diseases, and mainly the common respiratory infections, are major challenges to the current chemotherapy systems and, therefore, there is a requirement to find new compounds with therapeutic potential. The volatile natural compounds and essential oils are the main treasure agents in the natural compounds with antibiotic potential. The present chapter reviews natural traditional remedies used in the treatment of respiratory infections with the emphasis on antibacterial, antiviral, and antiinflammation activities of the volatile natural compounds (essential oils, etc.), and provides a brief view in some of structural activity relationships between antibacterial potencies and chemical structures of the essential oil’s constituents.

Influenza and respiratory syncytial viruses: Efficacy of different diagnostic assays

Objective:

To determine the efficacy of cell culture, immunoflourescence Assay (IFA) and real time polymerase chain reaction (rRT-PCR) in relation to diagnosis of influenza and Respiratory Syncytial Virus (RSV).

Methods:

Total 2781 specimens of throat swabs and nasopharyngeal aspirates were obtained from patients suspected of respiratory viruses’ infections from January 2009 to December 2011 at Universiti Kebangsaan Malaysia Medical Centre(UKMMC). The specimens were processed by cell culture and immunoflurescence assay (IFA) and (rRT-PCR).

Results:

Thirty three (1.19%) specimens were positive for influenza virus A and 42 (1.51%) were positive for RSV by cell culture and IFA. On the other hand, rRT-PCR was able to identify 189 of 505 (37.43%) specimens in which 65 were influenza A virus and 124 were RSV. Sensitivity of rRT-PCR was 100% for both influenza A virus and RSV and specificity was 88% and 77% for influenza A virus and RSV, respectively.

Conclusion:

rRT-PCR diagnosed respiratory viruses in shorter time with a high level of sensitivity in comparison to conventional assays - cell culture and IFA. These advantages help in managing patients by saving cost and hospitalization stay.

BP180- and BP230-specific IgG autoantibodies in pruritic disorders of the elderly: a preclinical stage of bullous pemphigoid?

Pruritus increasingly occurs in the elderly population and is associated with a variety of dermatoses of mixed aetiology. Clinical and experimental evidence suggests that senile pruritus may be linked to autoimmune events initiated by loss of self-tolerance against cutaneous autoantigens, which is facilitated by immune ageing processes. T-cell immunity, which underpins the production of pathogenic autoantibodies in autoimmune diseases, is deregulated by immune senescence thereby leading to autoimmune disorders such as bullous pemphigoid (BP). High mortality rates of BP combined with steadily increasing incidence emphasize the need for an effective diagnostic strategy at an early stage. We summarize here the current understanding of immunological alterations during the ageing process, thereby focusing on aberrant T-cell responses against the basement membrane antigens BP180 and BP230, which may eventually lead to the clinical outcome of BP.

Influenza and Respiratory Syncytial viral infections in Malaysia: Demographic and Clinical perspective

Objective: Respiratory infections represent a major public health problem worldwide. The study aimed to determine the prevalence of respiratory syncytial and influenza virus infections and analyzed in respect to demography and clinical perspective.

Methods: The specimens were processed by cell culture and immunofluorescent assay (IFA) and real-time reverse transcriptase-PCR (rRT-PCR) for detection of respiratory viruses.

Results: Out of 505 specimens 189 (37.8%) were positive, in which RSV was positive in 124(24.8%) cases and influenza A was positive in 65(13%) cases. Positive cases for influenza virus A and RSV were analyzed based on demography: age, gender, ethnicity and clinical symptoms. There were no significant differences among gender, ethnicity and clinical symptoms in both RSV and influenza A virus infections. It was observed that children below 3 years of ages were more prone to RSV infections. On the contrary, influenza virus A infected all age groups of humans.

Conclusion: RSV infects mostly child below 3 years of age and influenza virus infects all age group. No specificity of RSV and influenza infection in relation to demography.

Prevalence of influenza and adherence to the anti-flu vaccination among elderly

INTRODUCTION: The flu, a condition that can affect the elderly by increasing the risk of serious complications can be prevented through vaccination. Estimate the prevalence of signs and symptoms suggestive of influenza in a group of elderly either vaccinated or unvaccinated against influenza was the objective this study. METHODS: This is a cross-sectional study performed in a Brazilian City. A structured questionnaire was employed to identify the presence of signs and symptoms of influenza in individuals aged 60 years or over. For analysis of associations between variables the prevalence ratio (PR) and its 95% confidence interval (95% CI) were used. RESULTS: One hundred ninety-six participants were interviewed, of whom 57.7% were female. The average age was 69.7 years. About 25% of the vaccinated and 20% of the unvaccinated in 2009, and 25% of the vaccinated and 22.5% of the unvaccinated in 2010 reported having the flu. Among the vaccinated and unvaccinated in 2009 and 2010, there was no verified association between vaccination and influenza (PR=1.24; [95% CI: 0.63-2.43] and PR=1.11; [95% CI: 0.59-2.09], respectively). CONCLUSIONS: This study suggests that, among the elderly selected, the vaccination coverage for influenza is below the ideal, even with projection of the best indices for 2011 (~ 84%). The data on vaccination and disease protection needs further research; however, the results point to the need for measures to better clarify to this population about the disease, its complications and the benefits of vaccination, in addition to combatting the stigma related to low adherence.

Rates of hospitalizations for respiratory syncytial virus, human metapneumovirus, and influenza virus in older adults

BACKGROUND

We performed a prospective study to determine the disease burden of respiratory syncytial virus (RSV) and human metapneumovirus (HMPV) in older adults in comparison with influenza virus.

METHODS

During 3 consecutive winters, we enrolled Davidson County (Nashville, TN) residents aged ≥ 50 years admitted to 1 of 4 hospitals with acute respiratory illness (ARI). Nasal/throat swabs were tested for influenza, RSV, and HMPV with reverse-transcriptase polymerase chain reaction. Hospitalization rates were calculated.

RESULTS

Of 1042 eligible patients, 508 consented to testing. Respiratory syncytial virus was detected in 31 participants (6.1%); HMPV was detected in 23 (4.5%) patients; and influenza was detected in 33 (6.5%) patients. Of those subjects aged ≥ 65 years, 78% received influenza vaccination. Compared with patients with confirmed influenza, patients with RSV were older and more immunocompromised; patients with HMPV were older, had more cardiovascular disease, were more likely to have received the influenza vaccination, and were less likely to report fever than those with influenza. Over 3 years, average annual rates of hospitalization were 15.01, 9.82, and 11.81 per 10,000 county residents due to RSV, HMPV, and influenza, respectively.

CONCLUSIONS

In adults aged ≥ 50 years, hospitalization rates for RSV and HMPV were similar to those associated with influenza.

T-cell biology in aging, with a focus on lung disease

T cells are essential for defending hosts against microorganisms and malignancy as well as for regulating the development of immune-mediated inflammatory diseases like autoimmunity. Alterations in T-cell immunity occur with aging, affecting the function and proportions of T-cell subsets. Probably, the most noticeable age-associated change in T-cell immunity is an alteration in the frequency of naive and memory CD4+ and CD8+ T cells. In fact, the frequency of naive CD4+ and CD8+ T cells decreases with aging, whereas the frequency of memory CD4+ and CD8+ T cells increases. Also, changes in T-cell proliferation, cytokine production, memory response, and cytotoxicity as well as in regulatory T-cell number and function have been reported with aging. Such alterations could contribute to the development of infections, malignancies, and inflammatory diseases that rise with aging. Of interest, T cells are closely involved in the development of inflammatory airway and lung diseases including asthma and chronic obstructive pulmonary disease, which are prevalent in the elderly people. In addition, T cells play a major role in defending host against influenza virus infection, a serious medical problem with high morbidity and mortality in the elderly people. Thus, it is conceivable that altered T-cell immunity may account in part for the development of such respiratory problems with aging. Here, we will review the recent advances in T-cell immunity and its alteration with aging and discuss the potential effects of such changes on the lung.

Age-associated impaired plasmacytoid dendritic cell functions lead to decreased CD4 and CD8 T cell immunity

Increased susceptibility to infections, particularly respiratory viral infections, is a hallmark of advancing age. The underlying mechanisms are not well understood, and there is a scarcity of information regarding the contribution of the innate immune system, which is the first line of defense against infections. In the present study, we have investigated the effect of advancing age on plasmacytoid dendritic cell (PDC) function because they are critical in generating a robust antiviral response via the secretion of interferons (IFN). Our results indicate that PDCs from the aged are impaired in their capacity to secrete IFN-I in response to influenza virus and CPG stimulation. Additionally, we observed a severe reduction in the production of IFN-III, which plays an important role in defense against viral infections at respiratory mucosal surfaces. This reduction in IFN-I and IFN-III were a result of age-associated impaired phosphorylation of transcription factor, IRF-7. Furthermore, aged PDCs were observed to be impaired in their capacity to induce perforin and granzyme in CD8 T cells. Comparison of the antigen-presenting capacity of aged PDC with young PDC revealed that PDCs from aged subjects display reduced capacity to induce proliferation and IFN-gamma secretion in CD4 and CD8 T cells as compared with PDCs from young subjects. In summary, our study demonstrates that advancing age has a profound effect on PDC function at multiple levels and may therefore, be responsible for the increased susceptibility to infections in the elderly.

Nucleic acid amplification-based diagnosis of respiratory virus infections

The appearance of eight new respiratory viruses in the human population in the past 9 years, including two new pandemics (SARS coronavirus in 2003 and swine-origin influenza A/H1N1 in 2009), has tested the ability of virology laboratories to develop diagnostic tests to identify these viruses. Nucleic acid amplification tests (NATs) that first appeared two decades ago have been developed for both conventional and emerging viruses and now form the backbone of the clinical laboratory. NATs provide fast, accurate and sensitive detection of respiratory viruses and have significantly increased our understanding of the epidemiology of these viruses. Multiplex PCR assays have been introduced recently and several commercial tests are now available. The final chapter in the evolution of respiratory virus diagnostics will be the addition of allelic discrimination and detection of single nucleotide polymorphisms associated with antiviral resistance to multiplex assays. These resistance assays together with new viral load tests will enable clinical laboratories to provide physicians with important information for optimal treatment of patients.

Defective interfering virus protects elderly mice from influenza

BACKGROUND

We have identified and characterised a defective-interfering (DI) influenza A virus particles containing a highly deleted segment 1 RNA that has broad-spectrum antiviral activity. In young adult mice it exerts protection against several different subtypes of influenza A virus (defined here as homologous or genetically compatible protection) and against a paramyxovirus and an influenza B virus (heterologous or genetically unrelated protection). Homologous protection is mediated by replication competition between the deleted and full-length genomes, and heterologous protection occurs through stimulation of innate immunity, especially interferon type I.

METHODS

A single dose of the protective DI virus was administered intranasally to elderly mice at -7, -1 and +1 days relative to intranasal challenge with influenza A virus.

RESULTS

A single dose of the DI virus given 1 or 7 days protected elderly mice, reducing a severe, sometimes fatal disease to a subclinical or mild infection. In contrast, all members of control groups treated with inactivated DI virus before challenge became extremely ill and most died. Despite the subclinical/mild nature of their infection, protected mice developed solid immunity to a second infectious challenge.

CONCLUSIONS

The defective interfering virus is effective in preventing severe influenza A in elderly mice and may offer a new approach to protection of the human population.

Rho kinase as a therapeutic target in the treatment of asthma and chronic obstructive pulmonary disease

Asthma is a complex inflammatory disease of the airways involving reversible bronchoconstriction. Chronic obstructive pulmonary disease is typified by inflammation and airflow limitation that has an irreversible component. There is now substantial evidence that Rho kinase is involved in many of the pathways that contribute to the pathologies associated with these respiratory diseases including bronchoconstriction, airway inflammation, airway remodelling, neuromodulation and exacerbations due to respiratory tract viral infection. Indeed the Rho kinase inhibitor Y-27632 causes bronchodilatation and reduces pulmonary eosinophilia trafficking and airways hyperresponsiveness. Furthermore, accumulating evidence suggests that inhibition of Rho kinase could have a major beneficial impact on symptoms and disease progression in asthma and COPD by modulating several other systems and processes. Thus, the Rho kinase pathway may indeed be a worthwhile therapeutic target in the treatment of asthma and chronic obstructive pulmonary disease.

Detection of respiratory viruses by molecular methods

SUMMARY

Clinical laboratories historically diagnose seven or eight respiratory virus infections using a combination of techniques including enzyme immunoassay, direct fluorescent antibody staining, cell culture, and nucleic acid amplification tests. With the discovery of six new respiratory viruses since 2000, laboratories are faced with the challenge of detecting up to 19 different viruses that cause acute respiratory disease of both the upper and lower respiratory tracts. The application of nucleic acid amplification technology, particularly multiplex PCR coupled with fluidic or fixed microarrays, provides an important new approach for the detection of multiple respiratory viruses in a single test. These multiplex amplification tests provide a sensitive and comprehensive approach for the diagnosis of respiratory tract infections in individual hospitalized patients and the identification of the etiological agent in outbreaks of respiratory tract infection in the community. This review describes the molecular methods used to detect respiratory viruses and discusses the contribution that molecular testing, especially multiplex PCR, has made to our ability to detect respiratory viruses and to increase our understanding of the roles of various viral agents in acute respiratory disease.

Roles of human parainfluenza virus type 3 bases 13 to 78 in replication and transcription: identification of an additional replication promoter element and evidence for internal transcription initiation

The genomic promoter of human parainfluenza virus type 3 (HPIV3) contains multiple cis-elements controlling transcription and replication. Previous work showed that regions 1 to 12 and 79 to 96 were critical in promoting replication of an HPIV3 minireplicon, while the intergenic sequence and N gene start signal (IS/Ngs, bases 49 to 61) were important for transcription. Because these data were collected primarily using point mutations, not every base from position 1 to 96 was analyzed, and some important control elements may have been missed. To clarify the role of bases 13 to 78 in transcription and replication, a series of mutations were made which collectively scanned this entire region. Mutation of bases 13 to 28 resulted in markedly decreased HPIV3 minireplicon replication, indicating these bases constitute an additional cis-element involved in the synthesis of the HPIV3 antigenomic RNA. The position dependence of the IS/Ngs was also examined. Analysis of mutants in which the IS/Ngs was shifted 5' or 3' showed that this segment could be moved without significantly disrupting transcription initiation. Additional mutants which contained two successive IS/Ngs segments were created to test whether the polymerase accessed the gene start signal by proceeding along the template 3' to 5' or by binding internally at the gene start signal. Based on analysis of the double gene start mutants, we propose a model of internal transcription initiation in which the polymerase enters the template at approximately the location of the natural N gene start but then scans the template bidirectionally to find a gene start signal and initiate transcription.

Human coronavirus infection among children with acute lower respiratory tract infection in Thailand

OBJECTIVE

This study was performed to further identify the previously uncharacterized human coronavirus 229E (hCoV-229E) and human coronavirus OC43 (hCoV-OC43) in Thailand by using the RT-PCR technique. In addition, we performed this study in order to delineate the prevalence, the potential clinical impacts and evaluation of the genetic characterization of this pathogen in young children who presented with acute lower respiratory tract infections (ALRI).

METHODS

We obtained nasopharyngeal secretions (NPs) from 226 children <5 years of age who were either attending the outpatient department or hospitalized with ALRI from March 2002 to July 2003. All clinical, laboratory, RT-PCR, direct sequencing and phylogenetic analysis data were collected and analyzed.

RESULTS

Of the 226 NPs samples from infants and young children presented with ALRI, 8 (3.54%) were positive for hCoV-229E, 2 (0.88%) were positive for hCoV-OC43, and 1 (0.44%) had co-infection. The following clinical presentations were noted: fever (100%), rhinitis (44%), acute bronchiolitis (44%), viral pneumonia (33%), viral pneumonia triggering asthma exacerbation (11%) as well as viral pneumonia causing BPD exacerbation (11%). All positive samples were subjected to direct sequencing. The amino acid sequences had 82-99% similarity to previous sequences stored in the GenBank database.

CONCLUSION

The molecular technique we applied to detect human coronavirus appears justified as a valuable diagnostic approach to elucidate the prevalence, cause and clinical implications of ALRI among infants and young children.

Echinacea in the prevention of induced rhinovirus colds: a meta-analysis

BACKGROUND

The therapeutic effectiveness of Echinacea in the treatment and the prevention of colds has been debated. Studies of naturally occurring colds are hampered by variability in time from onset of symptoms to treatment and by heterogeneity in trial design. Experimental infection studies allow for the standardization of time to initiation of treatment, virus type and dose, and immune competence of volunteers.

OBJECTIVE

To determine whether the negative results obtained in previous studies of Echinacea were a consequence of efficacy or of inadequate sample size, we performed a meta-analysis of experimental rhinovirus infection studies on the efficacy of Echinacea extracts to prevent symptomatic development of an experimentally induced cold.

METHODS

We carried out a systematic search of English- and German-language literature using the MEDLINE, EMBASE, CAplus, BIOSIS, CABA, AGRICOLA, TOXCENTER, SCISEARCH, NAHL, and NAPRALERT, databases and the search terms Echinacea, black Sampson, coneflower, and Roter Sonnenbut. Matching documents were then searched for > or = 1 of the following terms: rhinovirus, RV, inoculation, Inokulation, induced, induziert, artificial, and artifiziell. Suitable studies were identified and pooled for analysis. The primary end point was the development of symptomatic clinical colds, as defined by the authors of the original studies. Results were reported as differences in the proportion of subjects with symptomatic episodes of a common cold, expressed as odds ratios (ORs) and 95% CIs. The secondary outcome was the difference in total symptom severity scores between treatment groups (assessed daily by integrating the severity scores of 8 individual cold-related symptoms that were rated on a scale from 0 [absent] to 4 [very severe]).

RESULTS

A total of 234 articles were identified through the literature search; 231 were excluded from the analysis because they related to studies of spontaneous common colds. Three suitable studies were selected for pooling of data. Based on the analysis, the likelihood of experiencing a clinical cold was 55% higher with placebo than with Echinacea (OR, 1.55 [95% CI, 1.02-2.36]; P<0.043). The absolute difference in total symptom scores between groups was -1.96 (95% CI, -4.83 to 0.90; P=NS).

CONCLUSIONS

This meta-analysis suggests that standardized extracts of Echinacea were effective in the prevention of symptoms of the common cold after clinical inoculation, compared with placebo. Further prospective, appropriately powered clinical studies are required to confirm this finding.

Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines

BACKGROUND

The purpose of this review is to present the evidence for the diagnosis and treatment of cough due to acute bronchitis and make recommendations that will be useful for clinical practice. Acute bronchitis is one of the most common diagnoses made by primary care clinicians and emergency department physicians. It is an acute respiratory infection with a normal chest radiograph that is manifested by cough with or without phlegm production that lasts for up to 3 weeks. Respiratory viruses appear to be the most common cause of acute bronchitis; however, the organism responsible is rarely identified in clinical practice because viral cultures and serologic assays are not routinely performed. Fewer than 10% of patients will have a bacterial infection diagnosed as the cause of bronchitis. The diagnosis of acute bronchitis should be made only when there is no clinical or radiographic evidence of pneumonia, and the common cold, acute asthma, or an exacerbation of COPD have been ruled out as the cause of cough. Acute bronchitis is a self-limited respiratory disorder, and when the cough persists for >3 weeks, other diagnoses must be considered.

METHODS

Recommendations for this review were obtained from data using a National Library of Medicine (PubMed) search dating back to 1950, which was performed in August 2004. The search was limited to literature published in the English language and human studies, using search terms such as "cough," "acute bronchitis," and "acute viral respiratory infection."

RESULTS

Unfortunately, most previous controlled trials guiding the treatment of acute bronchitis have not vigorously differentiated acute bronchitis and the common cold, and also have not distinguished between an acute exacerbation of chronic bronchitis and acute asthma as a cause of acute cough. For patients with the putative diagnosis of acute bronchitis, routine treatment with antibiotics is not justified and should not be offered. Antitussive agents are occasionally useful and can be offered as therapy for short-term symptomatic relief of coughing, but there is no role for inhaled bronchodilator or expectorant therapy. Children and adult patients with confirmed and probable whooping cough should receive a macrolide antibiotic and should be isolated for 5 days from the start of treatment; early treatment within the first few weeks will diminish the coughing paroxysms and prevent spread of the disease; the patient is unlikely to respond to treatment beyond this period.

CONCLUSION

Acute bronchitis is an acute respiratory infection that is manifested by cough and, at times, sputum production that lasts for no more than 3 weeks. This syndrome should be distinguished from the common cold, an acute exacerbation of chronic bronchitis, and acute asthma as the cause of acute cough. The widespread use of antibiotics for the treatment of acute bronchitis is not justified, and vigorous efforts to curtail their use should be encouraged.

A novel inhibitor of respiratory syncytial virus isolated from ethnobotanicals

A novel low molecular weight compound, CJ 4-16-4, isolated from ethnobotanicals using bioassay-guided fractionation, was found to be a potent inhibitor of respiratory syncytial virus (RSV) in vitro and in vivo. In vitro, a very low micromolar efficacious dose was obtained against at least four of subtype A (RSV-Long, RSV A2, and RSV A6 57754) and one of subtype B (Washington) RSV strains without seeing any significant cytotoxicity to Hep-2, MDCK or Vero cell lines. The drug inhibits growth of RSV in Hep-2 cells maintained in tissue culture at a very low concentration (approximately 0.07 microM) with cell toxicity >400 microM (TI>5880). In a cotton rat model of RSV infection, the drug was able to reduce viral titers by approximately 1 log at dose 12.5 and 25 mg/kg/day, and by >2 log at 100 mg/kg/day. This antiviral activity was specific as influenza A and B and herpes simplex 1 and 2 viruses were not inhibited. The results obtained indicate that CJ 4-16-4 warrants clinical development.

Response of aged mice to primary virus infections

Aging is associated with an increased morbidity to virus infections as well as a delay in clearance of symptoms after infection. Studies of sublethal virus infections of aged mice closely mirror the human situation: there is a delay in clearance of virus. The delay in virus clearance is accompanied by a delay and a decrease in T-cell response, particularly of CD8(+) T cells. Intrinsic alterations of T cells of aged mice contribute to this decrease in virus-specific T-cell response; however, evidence suggests that environmental or innate components of the aged host also influence this age-associated decline in clearance of virus. While the changes in the adaptive immune response have been carefully described, the early events in the generation of the T-cell response after virus infection have received limited attention. Importantly, age-associated changes in the innate response to virus infection, particularly production of and response to interferon (IFN)-alpha/beta, cytotoxicity and IFN-gamma production by natural killer cells, interleukin-12 induction, and depletion of non-specific T cells early during virus infection need further evaluation.

Vitamin E and respiratory infection in the elderly

Respiratory infections are prevalent in the elderly, resulting in increased morbidity, mortality, and utilization of health care services. Contributing to the increased incidence of infection with age is the well-described decline in immune response, which has been correlated with patterns of illness in the elderly. For example, there are higher morbidity and mortality from cancer, pneumonia, and post-operative complications in those who have diminished, delayed-type hypersensitivity skin test responses. Nutritional status is an important determinant of immune function. We have shown in double-blind, placebo-controlled trials that vitamin E supplementation significantly improved immune response, including DTH and response to vaccines. Furthermore, subjects receiving vitamin E in the 6-month trial had a 30% lower incidence of infectious diseases. That study, however, was not powered to demonstrate statistical significance, and the infections were self-reported. To overcome these limitations, we conducted a double-blind, placebo-controlled trial to determine the effect of one-year supplementation with 200 IU/day vitamin E on the incidence and duration of respiratory infections in 617 elderly nursing home residents. The results of this clinical trial show that vitamin E supplementation significantly reduces the incidence rate of common colds and the number of subjects who acquire a cold among elderly nursing home residents. A nonsignificant reduction in the duration of colds was also observed. Because of the high rate and more severe morbidity associated with common colds in this age group, these findings have important implications for the well being of the elderly as well as for the economic burden associated with their care.

Changes in mortalities and hospital admissions associated with holidays and respiratory illness: implications for medical services

RATIONALE AND OBJECTIVES

To see whether net mortalities increase during and after reductions in medical services, either at average weekends, or at Christmas when pressure from illness is unusually high.

METHODS

(1) Paired t-tests to compare mean daily deaths and hospital admissions during and after weekends (Saturday-Tuesday) with means for the week, in south-east England; (2) Linear regressions to see whether trends of daily deaths change when admissions are reduced at Christmas.

RESULTS

Neither mean daily all-cause, respiratory or ischaemic heart deaths exceeded weekly averages during weekends, or during Saturday-Monday or Saturday-Tuesday, despite falls in daily elective and daily emergency hospital admissions at weekends that averaged 61-72% and 14-22%, respectively. During 19-24 December, daily deaths were above annual means, respiratory deaths by 49% (29, 1-58), but elective admissions fell and although emergency admissions tended to rise, total admissions rose only for respiratory disease, and only by 33% (376, -47 to 799). On Christmas Day (25 December), even emergency admissions fell sharply below previous trends, respiratory emergency admissions by 18% (P<0.01). Respiratory deaths alone then immediately increased (P<0.01) above trend, by 5.9% (5.8 deaths/day) on 26 December and by 12.9% (12.9) on 27 December.

CONCLUSIONS

No adverse effect on mortality was apparent within 2 days from reduction in medical services at weekends. However, respiratory deaths accelerated sharply after reduction in elective and emergency admissions at Christmas, when rates of infection and mortality from respiratory disease were high. Implications for medical services during respiratory epidemics are discussed.

Management of acute bronchitis in healthy adults

Acute respiratory infections (ARIs) are the most common infections in humans, accounting for half of all acute conditions each year in the United States. Acute bronchitis episodes represent a significant portion of these illnesses. This article focuses on acute bronchitis in otherwise healthy individuals.

Respiratory virus infections in Stockholm during seven seasons: a retrospective study of laboratory diagnosis

A retrospective analysis of the virological findings in all respiratory samples (7303) analysed at the laboratory of Karolinska Hospital between 1993 and 2000 was performed. The findings were studied according to age and seasonal variation, and the methods were evaluated. Most samples were from children. RSV was the dominant agent, found in 34% of all samples from children 0-1 y of age. Influenza A was found in 13% of samples from the age group 2-5 y. Influenza A dominated among adults and the elderly. RSV was found only in 2% of samples from patients 81 y or older. Adenovirus was found among children and adults, but not at all among the elderly. Both antigen detection and virus isolation were performed on 79% (5776) of the samples. For diagnosis of influenza A, virus isolation was more sensitive than immunofluorescence, but for diagnosis of RSV immunofluorescence was more sensitive than virus isolation. Thus, the analysis verified that influenza A is common not only among adults and the elderly, but also among small children. RSV was an uncommon finding among the elderly. Immunofluorescence is sensitive and rapid for the diagnosis of particularly RSV among small children and influenza in all age groups.

Influenza circulating strains in Argentina exhibit differential induction of cytotoxicity and caspase-3 in vitro

BACKGROUND

Human influenza infections are a significant cause of morbidity worldwide. Though damage to the respiratory epithelium and has been related to apoptosis, which occurs subsequent to influenza virus infection, little information is available regarding cell cytotoxicity of human strains.

OBJECTIVE

To study cytotoxicity performed in vitro by various circulating strains in Argentina. The study sample consisted of three vaccine strains (H1N1, H3N2, and B) administered during 1999-2000 in South America and three strains isolated from clinical samples, one, NAC (H1N1) obtained from an adult inpatient with human pneumonia; and the other two (T) and (T2) (H3N2) with influenza syndrome. Viral antigen was detected by an immunofluorescence test, conducted prior to viral isolation in MDCK cells. Strains were subtyped by the hemmaglutination inhibition test. Cytotoxic properties were determined by lactate dehydrogenase reaction (LDH), crystal violet staining and Hoechst staining. Caspase-3 activity, morphological changes of apoptosis, and viral yields were measured in MDCK infected cells.

RESULTS AND CONCLUSIONS

Cells infected by each of the strains exhibited apoptosis morphology by Hoechst staining and caspase-3 activity was high for both H1N1 strains. Further, high levels of LDH activity were detected for NAC and H3N2 strains tested, indicating the possible role of different viral proteins or functions on cell cytotoxicity. The NAC strain, isolated from human pneumonia and antigenically related to A/New Caledonia /20/99 (H1N1), was the highest cytotoxic strain and an excellent inducer of caspase-3 activity. In turn, no parameter was related to different viral yields. We conclude that human strains studied in this paper may be useful tools in the characterization of molecular determinants involved in viral cytopathogenicity.

Vitamin E and respiratory tract infections in elderly nursing home residents: a randomized controlled trial

CONTEXT

Respiratory tract infections are prevalent in elderly individuals, resulting in increased morbidity, mortality, and use of health care services. Vitamin E supplementation has been shown to improve immune response in elderly persons. However, the clinical importance of these findings has not been determined.

OBJECTIVE

To determine the effect of 1 year of vitamin E supplementation on respiratory tract infections in elderly nursing home residents.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, double-blind, placebo-controlled trial was conducted from April 1998 to August 2001 at 33 long-term care facilities in the Boston, Mass, area. A total of 617 persons aged at least 65 years and who met the study's eligibility criteria were enrolled; 451 (73%) completed the study.

INTERVENTION

Vitamin E (200 IU) or placebo capsule administered daily; all participants received a capsule containing half the recommended daily allowance of essential vitamins and minerals.

MAIN OUTCOME MEASURES

Incidence of respiratory tract infections, number of persons and number of days with respiratory tract infections (upper and lower), and number of new antibiotic prescriptions for respiratory tract infections among all participants randomized and those who completed the study.

RESULTS

Vitamin E had no significant effect on incidence or number of days with infection for all, upper, or lower respiratory tract infections. However, fewer participants receiving vitamin E acquired 1 or more respiratory tract infections (60% vs 68%; risk ratio [RR], 0.88; 95% confidence interval [CI], 0.76-1.00; P =.048 for all participants; and 65% vs 74%; RR, 0.88; 95% CI, 0.75-0.99; P =.04 for completing participants), or upper respiratory tract infections (44% vs 52%; RR, 0.84; 95% CI, 0.69-1.00; P =.05 for all participants; and 50% vs 62%; RR, 0.81; 95% CI, 0.66-0.96; P =.01 for completing participants). When common colds were analyzed in a post hoc subgroup analysis, the vitamin E group had a lower incidence of common cold (0.67 vs 0.81 per person-year; RR, 0.83; 95% CI, 0.68-1.01; P =.06 for all participants; and 0.66 vs 0.83 per person-year; RR, 0.80; 95% CI, 0.64-0.98; P =.04 for completing participants) and fewer participants in the vitamin E group acquired 1 or more colds (40% vs 48%; RR, 0.83; 95% CI, 0.67-1.00; P =.05 for all participants; and 46% vs 57%; RR, 0.80; 95% CI, 0.64-0.96; P =.02 for completing participants). Vitamin E had no significant effect on antibiotic use.

CONCLUSIONS

Supplementation with 200 IU per day of vitamin E did not have a statistically significant effect on lower respiratory tract infections in elderly nursing home residents. However, we observed a protective effect of vitamin E supplementation on upper respiratory tract infections, particularly the common cold, that merits further investigation.

Uncinoside A and B, two new antiviral chromone glycosides from Selaginella uncinata

Five compounds have been isolated from the dried whole plants of Selaginella uncinata, two of them were new chromone glycosides, 5-hydroxy-2,6,8-trimethylchromone 7-O-beta-D-glucopyranoside (uncinoside A) and 5-acetoxyl-2,6,8-trimethylchromone 7-O-beta-D-glucopyranoside (uncinoside B). Their structures were elucidated by spectroscopic methods including one- and two-dimensional NMR techniques. The other three compounds were identified as 8-methyl eugenitol, amentoflavone and hinokiflavone. Uncinoside A and B showed potent antiviral activities against respiratory syncytial virus (RSV) with IC(50) value of 6.9 and 1.3 microg/ml, moderate antiviral activities against parainfluenza type 3 virus (PIV 3) with IC(50) value of 13.8 and 20.8 microg/ml, respectively.

Orally active fusion inhibitor of respiratory syncytial virus

BMS-433771 was found to be a potent inhibitor of respiratory syncytial virus (RSV) replication in vitro. It exhibited excellent potency against multiple laboratory and clinical isolates of both group A and B viruses, with an average 50% effective concentration of 20 nM. Mechanism-of-action studies demonstrated that BMS-433771 inhibits the fusion of lipid membranes during both the early virus entry stage and late-stage syncytium formation. After isolation of resistant viruses, resistance was mapped to a series of single amino acid mutations in the F1 subunit of the fusion protein. Upon oral administration, BMS-433771 was able to reduce viral titers in the lungs of mice infected with RSV. This new class of orally active RSV fusion inhibitors offers potential for clinical development.

Lung infections and aging

Respiratory tract infections are the leading cause of death due to infectious disease in the elderly. Many factors, especially waning immune responses and the onset of age-associated organ dysfunction, likely account for an increase in susceptibility to respiratory tract infection in the elderly, and morbidity and mortality rates are substantially greater for the elderly when outcomes are compared to that of younger individuals. The presence of underlying disease states such as chronic obstructive pulmonary disease (COPD) or other organ system disease further increases the likelihood of developing severe pneumonia in the elderly population, and the frail elderly, particularly when institutionalized in chronic care facilities, are at high risk for developing severe and recurrent pneumonia. This article will discuss various factors associated with advanced age that predispose the elderly to respiratory infections and summarize current approaches to treatment and prevention.

Drug Therapy in Transplant Recipients

Elderly patients with end-stage organ failure are now more frequently undergoing transplantation. Medication management in this population is challenging because of the combination of multiple comorbidities, polypharmacy, and immunological, pharmacokinetic and pharmacodynamic changes attributable to the aging process. Immunosuppressive medications can exacerbate pre-existing medical conditions and promote the development of disease processes. Cardiovascular disorders, such as hypertension, coronary artery disease, congestive heart failure and arrhythmias are common in elderly transplant recipients, and account for most of the deaths in this population. Blood pressure, blood glucose and cholesterol control is of particular concern because elderly transplant recipients frequently have or develop these complications. Elderly transplant recipients are commonly receiving anticoagulation therapy with warfarin and are at a higher risk of bleeding, especially if they have renal dysfunction. Infectious complications occur frequently in the transplanted population, with pneumonia being the most common infection seen in hospitalised patients. Attention to vaccination for the prevention of influenza and pneumococcal infections is important because of the increased risk of these diseases in this population. Depression itself has been associated with decreased survival in older individuals, and depression in elderly transplant recipients may be reversible with the administration of pharmacological agents. Effective long-term care of transplant recipients demands an understanding of how particular medications affect clinical evaluation and treatment. This article addresses some of the practical issues surrounding medication management and prevention of these particular problems in elderly transplant recipients.

The immunogenicity, protective efficacy and safety of BBG2Na, a subunit respiratory syncytial virus (RSV) vaccine candidate, against RSV-B

Respiratory syncytial virus (RSV) is divided into subgroups A and B, based primarily on variation within the G glycoprotein. A safe vaccine that protects against both would be the ideal. BBG2Na is a recombinant subunit RSV vaccine candidate derived in part from the G protein of RSV-A. Interestingly, BBG2Na formulated in alum protected against RSV-B challenge at early time points following vaccination in mice. Over 6 months, however, BBG2Na-induced immunogenicity and protective efficacy progressively diminished, such that few animals were considered protected at the end. To study the safety of BBG2Na relative to RSV-B challenge, we established a novel enhanced immunopathology mouse model. We confirmed that RSV-B challenge of formalin-inactivated RSV-A (FI-RSV-A)-immunized BALB/c mice results in enhanced pulmonary pathology. Therefore, this phenomenon is neither subgroup-specific nor dependent on a previously incriminated Th epitope in the RSV-A G protein. In stark contrast, BBG2Na did not induce any signs of enhanced pulmonary pathology. In conclusion, our data indicate that BBG2Na, formulated in alum, induces safe and protective immune responses against RSV-B challenge in mice. However, the duration of protective immunity will probably be insufficient to prevent RSV-B infection for the duration of the RSV epidemic season.

[Severe acute respiratory syndrome]

In the Fall of 2002 a report from Guangdong Province in China showed the occurrence of an outbreak of atypical pneumonia. This outbreak rapidly progressed from China to Hong Kong, Singapore, Toronto, and the USA, to more than 25 countries worldwide and almost 3500 cases to date in april 2003. The clinical features associate a fever with mild respiratory symptoms which can progress to a typical acute respiratory distress syndrome requiring intensive care unit admission. Enteric forms with diarrhea were recently described in Hong Kong. The medical community responded very rapidly and united in front of this major health crisis. In a couple weeks, the agent, a new Coronavirus was isolated, therapeutic guidelines were proposed and measures to limit the outbreak diffusion were started worldwide. We summarize here the history of the outbreak, the clinical, laboratory and radiological features of SARS. April 2003 therapeutic guidelines are also reported.

Molecular structures and antiviral activities of naturally occurring and modified cassane furanoditerpenoids and friedelane triterpenoids from Caesalpinia minax

Further investigation of the active components of the chloroform fraction of the seeds of Caesalpinia minax led to the isolation of a new cassane furanoditerpenoid, caesalmin H (1), together with two known furanoditerpenoid lactones, caesalmin B (2) and bonducellpin D (3). Reduction of the naturally abundant caesalmin D (9), E (10) and F (11) resulted in three new furanoditerpenoid derivatives 4-6. Phytochemical study of the stem of the same plant and subsequent reduction afforded two friedelane triterpenoids (7-8), which were identified by spectroscopic methods. Compounds 1-2 and 4-8 were corroborated by single crystal X-ray analysis. The factors governing the reduction of cassane furanoditerpenoids and friedelane triterpenoids were investigated by correlating the crystallographic results with density functional theory. The inhibitory activities of 2-8 on the Para3 virus were evaluated by cytopathogenic effects (CPE) reduction assay.

Apoptosis and reduced influenza A virus specific CD8+ T cells in aging mice

Some studies have reported increased apoptosis in CD8(+) T cells from aged mice. We previously demonstrated diminished virus-specific CD8(+) cytotoxic T lymphocyte (CTL) activity in aged mice in comparison to young mice. The present study investigated the role of apoptosis in age-related influenza virus-specific CD8(+) CTL deficiency. Splenocytes from influenza-primed aged and young mice were stimulated in vitro with virus. The CD8(+) T cell/total lymphocyte ratios correlated with CTL activity and were significantly decreased and increased in aged and young mice, respectively. Fas, FasL, TNF-alpha and TNFR-p55 expression, measured by flow cytometry, ELISA and/or RT-PCR, were significantly elevated in aged mice. Apoptotic CD8(+) T cells (Annexin V binding) were also elevated in aged mice. IL-12 treatment increased CD8(+) CTL activity and IFN-gamma production but did not affect apoptosis. Thus, apoptosis may contribute to reduced influenza virus-specific CD8(+) T cell frequency, CTL deficiency and increased influenza disease in aging.

Influenza and the work of the World Health Organization

Before World War I, influenza was not considered a particularly serious problem. The great pandemic of 1918-1919 changed all that, and the possibility that such a catastrophe could occur again has conditioned all subsequent developments. In epidemiological terms, the hallmark of an influenza is the excess mortality that it causes combined with an enormous burden of ill-health that saps the energy of individuals, families and communities throughout the whole world. In order to engage in influenza prevention and control, the global influenza surveillance network was set up by World Health Organization (WHO) in 1948 as a worldwide alert system for the identification of new influenza viruses, gathering information from 110 participating laboratories in 82 countries and four WHO Collaborating Centers for Influenza reference and research: Centers for Disease Control and Prevention, Atlanta (USA), National Institute for Medical Research, London (UK), WHO Collaborating Centre for Influenza Reference and Research, Melbourne (Australia) and the National Institute for Infectious Diseases, Tokyo (Japan). This network helps WHO to monitor influenza activity all over the world and provides the organization with the viral isolates and information it requires to decide which new virus strains will be used to produce influenza vaccines during the following season. Each year, information about the isolates over the previous 12 months is analyzed and used to determine the composition of the influenza vaccine to be administered during the coming influenza season both for the northern and southern hemisphere. If necessary, the recommendations for the southern hemisphere differ from the ones formulated for the northern hemisphere vaccine. The information supplied by this network enables the organization to regularly update its World Wide Web (WWW) site (FluNet), which reports on the situation of diseases. This network will also enable the WHO to detect a new influenza pandemic as early as possible.

Respiratory viral infections in adults

Respiratory viral infections in adults cause significant morbidity and mortality, especially in high-risk patients. The impact of influenza virus, rhinoviruses, and respiratory syncytial virus in immunocompromised cancer patients and in asthma and chronic bronchitis patients has been documented in recent publications. Cytomegalovirus pneumonia continues to be a major cause of morbidity and mortality in transplant recipients. Newer rapid diagnostic tests and the use of polymerase chain reaction technology have provided better understanding of the causes and epidemiology of acute respiratory illness in adults. The approved neuraminidase inhibitors for influenza viruses and the nonapproved capsid inhibitors of rhinoviruses may be useful in treating high-risk individuals. The inactivated influenza vaccine has been shown to benefit healthy adults and to be safe in asthmatic adults and children.

The humoral response to live and inactivated influenza vaccines administered alone and in combination to young adults and elderly

BACKGROUND

Vaccination is the most effective way for prevention of severe influenza infection, but the present vaccines are not very efficient in the elderly.

OBJECTIVE

In this study, we investigated the Ig isotype response to a cold adapted, live, attenuated influenza vaccine (LIV) and a trivalent, subunit, inactivated influenza vaccine (IIV) and the combination of both (LIV/IIV) in young and elderly men, not previously vaccinated against influenza.

STUDY DESIGN

LIV and IIV containing the strains for 1998-1999 were used. Forty-seven 19-35 years old and forty-three 58-91 years old were divided in four groups receiving either LIV, IIV, both or placebo. All were bled before and at 4 weeks after vaccination. The hemagglutination inhibition (HAI) antibody response to homologous strains and the enzyme-linked immunosorbent assays (ELISA) IgA, IgG and IgG-subclass responses to recombinant HA proteins representing influenza A and B strains from 90 to 91, and purified virus from an A/Sydney/05/97-like strain were measured.

RESULTS

Protective HAI titers of >40 were more frequent (P<0.05) after IIV alone or LIV/IIV than after LIV alone; there was no difference between the young and elderly persons. The highest frequency of titer rises in ELISA was found against the H1N1 recombinant antigen. In young adults, IgG titer rises were more frequent than in elderly given LIV than IIV alone, but not when given the combination. The influenza-specific IgG subclass response after LIV consisted of IgG1 and IgG4 only in the young; after IIV it stimulated of IgG1 and IgG3 in the young and IgG1 alone in the elderly. After vaccination with the LIV/IIV combination IgG1, IgG3 and IgG4 were found in the young and IgG1, IgG3 in the elderly. Among the elderly, the IIV/LIV combination induced the same response rate of specific IgG and IgG1 as in young adults.

CONCLUSION

The study illustrates the possibility to correct the age dependent weakening of the immune response to influenza vaccine with a combination of LIV and IIV.

Antiviral Chinese medicinal herbs against respiratory syncytial virus

Forty-four medicinal herbs were tested for antiviral activities against respiratory syncytial virus (RSV) by means of the cytopathologic effect (CPE) assay. Twenty-seven of the 44 medicinal herbs showed potent or moderate antiviral activities against RSV with 50% inhibition concentration (IC(50)) ranging from 6.3 to 52.1 microg/ml, and with selectivity index (SI) ranging from 2.0 to 32.1. Further purification of the active extracts from Sophora flavescens Ait. and Scutellaria baicalensis Georgi led to the identification of anagyrine (2), oxymatrine (7), sophoranol (10), wogonin (12), and oroxylin A (13) as the potent anti-RSV components.