Application of Directigen FLU-A for the detection of influenza A virus in human and nonhuman specimens

Comparative examination of a rapid immunocytochemical test for the detection of highly pathogenic avian influenza virus in domestic birds in field outbreaks

RESEARCH HIGHLIGHTS

Avian influenza virus (AIV) antigen detection was examined in field outbreaks.Bird brain smears were tested using immunocytochemistry (IC).IC results strongly correlated with real-time RT-PCR results.The IC method was rapid, specific, sensitive, and cost-effective in AIV field outbreaks.

The evaluation of three diagnostic tests for the detection of equine influenza nucleoprotein in nasal swabs

Background

Equine influenza (EI) is a highly contagious respiratory disease of horses.

Objectives

The aim of this study was to evaluate two rapid antigen detection kits (Directigen or DFA, and Espline) and a commercial ELISA for the detection of EI nucleoprotein in nasal swabs.

Method

Nasal swab samples from naturally and experimentally infected horses were used to compare the sensitivity and specificity of these assays to virus isolation (VI) and real-time RT-PCR.

Results

If real-time RT-PCR was considered as the gold standard, the sensitivity of the other tests in field samples was 68% (DFA), 35% (ELISA), 29% (Espline), and 9% (VI). These tests had 100% specificity when compared to real-time RT-PCR. A receiver operating characteristic (ROC) curve indicated that decreasing the cutoff of the ELISA would increase sensitivity with some loss of specificity. In samples from experimentally infected horses, the sensitivity of the tests compared with real-time RT-PCR was 69% (VI), 27% (DFA), 6% (Espline), and 2% (ELISA). The specificity was 100% for Espline and ELISA and 95% for VI and DFA.

Conclusions

This study illustrated that DFA is the most sensitive antigen detection test evaluated for the diagnosis of EI and that it can detect virus in some subclinical infected and vaccinated horses. The results suggest that DFA is a useful adjunct to laboratory tests and may be effective as a screening test in a quarantine station or similar facility where horses are monitored daily.

Viral shedding duration of pandemic influenza A H1N1 virus during an elementary school outbreak--Pennsylvania, May-June 2009

We report shedding duration of 2009 pandemic influenza A (pH1N1) virus from a school-associated outbreak in Pennsylvania during May through June 2009. Outbreak-associated students or household contacts with influenza-like illness (ILI) onset within 7 days of interview were recruited. Nasopharyngeal specimens, collected every 48 hours until 2 consecutive nonpositive tests, underwent real-time reverse transcriptase polymerase chain reaction (rRT-PCR) and culture for pH1N1 virus. Culture-positive specimens underwent virus titrations. Twenty-six (median age, 8 years) rRT-PCR-positive persons, for pH1N1 virus, were included in analysis. Median shedding duration from fever onset by rRT-PCR was 6 days (range, 1-13) and 5 days (range, 1-7) by culture. Following fever resolution virus was isolated for a median of 2 days (range, 0-5). Highest and lowest virus titers detected, 2 and 5 days following fever onset, were 3.2 and 1.2 log(10) TCID(50)/mL respectively. Overall, shedding duration in children and adults were similar to seasonal influenza viruses.

Sensitivity of influenza rapid diagnostic tests to H5N1 and 2009 pandemic H1N1 viruses

Simple and rapid diagnosis of influenza is useful for making treatment decisions in the clinical setting. Although many influenza rapid diagnostic tests (IRDTs) are available for the detection of seasonal influenza virus infections, their sensitivity for other viruses, such as H5N1 viruses and the recently emerged swine origin pandemic (H1N1) 2009 virus, remains largely unknown. Here, we examined the sensitivity of 20 IRDTs to various influenza virus strains, including H5N1 and 2009 pandemic H1N1 viruses. Our results indicate that the detection sensitivity to swine origin H1N1 viruses varies widely among IRDTs, with some tests lacking sufficient sensitivity to detect the early stages of infection when the virus load is low.

Validation of a method for preparing influenza H5N1 simulated samples

Avian influenza virus type A subtype H5N1 and potentially other novel influenza A viruses continue to pose a concern with mutation into a form easily transmitted between humans. The ability to rapidly detect and characterize influenza viruses, and distinguish seasonal and novel influenza A viruses such as H5N1, remains important to minimize morbidity and mortality in humans. As with other rare and emerging viral pathogens, clinical specimens from persons with H5N1 infections are extremely rare. Consequently, development of standardized methods and accepted criteria are necessary for both ensuring the validity of available diagnostic methods and for assessing the potential of new diagnostic tests that can detect and differentiate H5N1 and other novel influenza A viruses. Additionally, genotypic and antigenic evolution of H5N1 poses a challenge with maintaining updated reference virus strains. In this report, a method for preparing simulated samples using defined procedures and carefully selected H5N1 virus strains is described, and the reliability for using these samples in an evaluation protocol with a laboratory test for differentiating H5N1 virus from other influenza A viruses is evaluated.

[Seasonal flu]

La grippe saisonnière est due aux virus influenza A et B. Il s’agit de virus enveloppés dont le génome est constitué de sept à huit fragments d’ARN. Les différents sous-types sont déterminés par la nature des deux glycoprotéines de surface HA et NA. La grippe saisonnière est une maladie épidémique et hivernale dans les zones à climat tempéré. Son épidémiologie est liée à la grande variabilité du virus au cours du temps, nécessitant la mise en place d’un système d’alerte détectant chaque année les variants circulants dominant et déterminant la composition vaccinale. Les symptômes cliniques de la grippe ne sont pas suffisamment spécifiques pour permettre le diagnostic sans examen virologique. Cela est particulièrement vrai en période non épidémique, chez les sujets de plus de 65 ans et chez les enfants de moins de cinq ans. L’enfant représente une cible privilégiée des infections à virus influenza. Le recours à l’hospitalisation est d’autant plus élevé que l’enfant est jeune. Chez le nourrisson, l’infection peut être paucisymptomatique et s’accompagner de manifestations non respiratoires (léthargie, convulsions, malaises). Le diagnostic virologique de la grippe est justifié chez tous les sujets hospitalisés pour un syndrome respiratoire compatible avec une infection à virus influenza. Il existe plusieurs outils permettant une recherche directe du virus dans les sécrétions respiratoires : isolement du virus en culture, détection d’antigènes, détection moléculaire de l’ARN. Le choix de la méthode se fait selon les caractéristiques du test : sensibilité, spécificité, rapidité et simplicité de réalisation, coût.

Detection of NP, N3 and N7 antibodies to avian influenza virus by indirect ELISA using yeast-expressed antigens

BACKGROUND

Avian influenza viruses, belonging to the family Orthomyxoviridae, possess distinct combinations of hemagglutinin (H) and the neuraminidase (N) surface glycoproteins. Typing of both H and N antigens is essential for the epidemiological and surveillance studies. Therefore, it is important to find a rapid, sensitive, and specific method for their assay, and ELISA can be useful for this purpose, by using recombinant proteins.

RESULTS

The nucleoprotein (NP) and truncated neuraminidase subtype 3 and 7 of avian influenza virus (AIV) were expressed in Saccharomyces cerevisiae and used to develop an indirect enzyme-linked immunosorbent assay for antibody detection. The developed assays were evaluated with a panel of 64 chicken serum samples. The performance of NP-ELISA was compared with the commercially available ProFlok AIV ELISA kit. The results showed comparable agreement and sensitivity between the two tests, indicating that NP-ELISA assay can be used for screening the influenza type A antibody in AIV infected birds. The N3 and N7- ELISAs also reacted specifically to their type specific sera and did not exhibit any cross-reaction with heterologous neuraminidase subtype specific sera.

CONCLUSION

The study demonstrates the expression of the NP, N3, and N7 proteins of AIV in yeast (S. cerevisiae) and their application in developing an indirect ELISA for detecting NP, N3 and N7 antibodies from AIV-infected chicken sera. The described indirect ELISAs are rapid, sensitive, specific and can be used as promising tests during serological surveillance.

Conventional and future diagnostics for avian influenza

The significant and continued transboundary spread of Asian avian influenza H5N1 since 2003, paired with documented transmission from avian species to humans and other mammals, has focused global attention on avian influenza virus detection and diagnostic strategies. While the historic and conventional laboratory methods used for isolation and identification of the virus and for detection of specific antibodies continued to be widely applied, new and emerging technologies are rapidly being adapted to support avian influenza virus surveillance and diagnosis worldwide. Molecular tools in particular are advancing toward lab-on-chip and fully integrated technologies that are capable of same day detection, pathotyping, and phylogenetic characterization of influenza A viruses obtained from clinical specimens. The future of avian influenza diagnostics, rather than moving toward a single approach, is wisely adopting a strategy that takes advantage of the range of conventional and advancing technologies to be used in "fit-for-purpose" testing.

Performance of Directigen flu A+B enzyme immunoassay and direct fluorescent assay for detection of influenza infection during the 2004-2005 season

Early diagnosis of influenza infection is needed to optimize the benefit of prescribing antiviral drugs. However, the accuracy of rapid tests is highly variable. This study evaluated the performance of Directigen flu A+B enzyme immunoassay (EIA) and direct fluorescent assay (DFA) during the 2004-2005 influenza season. Participants with medically attended acute respiratory illness were identified through an active surveillance. Consenting patients (n=818) were enrolled and cultured for influenza. Physicians ordered a rapid antigen test (EIA or DFA) according to their clinical judgment. Physicians ordered rapid tests with EIA (n=109), DFA (n=86), or both (n=9) in 204 patients with acute respiratory illness who were also cultured for influenza. The EIA detected 18 of 43 influenza infections (sensitivity, 42%; 95% confidence interval [CI], 28-57%), whereas DFA detected 26 of 38 influenza infections (sensitivity, 68%; 95% CI, 53-81%). Compared with culture, specificity of both EIA and DFA was 96%. During the 2004-2005 influenza season, both the EIA and DFA had low sensitivity and failed to detect influenza in many patients.

Review of Rapid Molecular Diagnostic Tools for Avian Influenza Virus

Molecular diagnostic tests are commonly used to diagnose avian influenza virus because they are sensitive and can be performed rapidly, with high throughput, and at a moderate cost. Molecular diagnostic tests recently have proven themselves to be invaluable in controlling disease outbreaks around the world. Several different methods, including traditional reverse transcription-polymerase chain reaction (PCR), real-time reverse transcription-polymerase chain reaction, and nucleic acid sequence-based amplification among others, have been described for the diagnosis of avian influenza in poultry with many different variations of primers, probes, enzymes, etc. Few of these tests have been validated, with the understanding that validation should be described as a level of comparison testing to show "fitness for purpose." None of the molecular diagnostic tests are validated for all species or specimen types that might be presented to a diagnostic laboratory. The sensitivity and specificity for all the molecular tests are governed by three critical control points, including RNA extraction, enzymes used for amplification, and the sequence of primers and probes. The RNA extraction step is of particular concern, since high-quality RNA is needed for any of the molecular tests. Some sample types, including cloacal (fecal) swabs and tissues, are difficult to process, with issues of poor RNA extraction or PCR inhibitors being common. The development of internal controls, robotics, and bead reagents are providing improved performance of existing tests, and new technologies will likely provide better tests for the future. With any molecular test, assay assurance must be performed on an ongoing basis, which includes the use of proficiency panels to measure test performance.

Comparative analytical sensitivities of six rapid influenza A antigen detection test kits for detection of influenza A subtypes H1N1, H3N2 and H5N1

BACKGROUND

Rapid and simple methods for diagnosing human influenza A (H5N1) disease urgently needed. The limited data so far suggest that the currently available rapid antigen detection kits have poor clinical sensitivity for diagnosis of human H5N1 disease.

OBJECTIVES

To compare the analytical sensitivity of six commercially available rapid antigen detection kits for the detection of "human" (subtypes H1N1, H3N2) and "avian" (subtype H5N1) influenza A viruses.

STUDY DESIGN

Six commercially available test kits for the detection of influenza A were investigated. Analytic sensitivity for the detection of two contemporary H1N1, two H3N2 and three H5N1 viruses was determined using virus culture as a reference method.

RESULTS AND CONCLUSIONS

Each test kit detected the H5N1 virus subtypes as efficiently as they detected conventional human viruses of subtypes H1N1 or H3N2. However, limits of detection of influenza viruses of all subtypes by antigen detection kits were >1000-fold lower than virus isolation. Thus, the reportedly poor clinical sensitivity of these antigen detection kits for diagnosis of patients with H5N1 disease is not due to a difference of sensitivity for detecting avian influenza H5N1 compared to human influenza viruses.

Comparison of two rapid influenza A/B test kits with reference methods showing high specificity and sensitivity for influenza A infection

The rapid detection of influenza viruses is important for forming preventative strategies, directing initiation of anti-viral therapy, detecting potential avian influenza viruses, and excluding influenza-like pathogens, such as SARS. The ImmunoCard STAT! Flu A and B Plus test (Meridian Bioscience, Cincinnati, OH) is a new point of care (POC) test utilizing influenza-specific monoclonal antibodies for rapid diagnosis. The performance of this assay was compared to the established POC Binax NowFlu A and NowFlu B test, and the reference diagnostic standards of viral culture, indirect immunofluorescence (IFA), and RT-PCR where appropriate. Testing of nasopharyngeal aspirates (NPA) from children, throat swabs, and nasal swabs from adults indicated ImmunoCard STAT! specificity of 98% and 100% for influenza A and B, respectively in 224 specimens. The Binax test showed specificity of 99% and 100%, respectively for influenza A and B. Sensitivity results were identical for both rapid detection kits (80% and 47% for Flu A and B, respectively). Overall results were very similar for both testing devices with the advantage of ImmunoCard STAT! Flu A and B Plus test detecting influenza A and B with sharp and easy to read results.

Commercial Immunoassay Kits for the Detection of Influenza Virus Type A: Evaluation of Their Use with Poultry

Five antigen capture immunoassay test kits, Directigen Flu A (Becton Dickinson), QuickVue Influenza test kit (Quidel), FLU OIA (ThermoBiostar), Zstat Flu (ZymeTx, Inc.) and NOW FLU A Test (Binax) were used to detect avian influenza virus (AIV) in clinical specimens as per manufacturers' protocols. Each kit was shown to be specific for AIV propagated in embryonating chicken eggs (ECE); other respiratory viruses of poultry tested gave negative results. The Directigen Flu A kit proved to be 10-fold more sensitive than the other kits, capable of detecting 10(4.7) mean embryo lethal dose (ELD50)/ml in allantoic fluid; this is more sensitive than the hemagglutination test using chicken erythrocytes. None of the kits proved to be sufficiently sensitive to reliably detect AIV in oropharyngeal and cloacal swabs collected from chickens experimentally infected with AIV subtype H6N2. In two different experiments, individual swabs and pools of five or six swabs were tested. By virus isolation, 39 individual oropharyngeal swabs tested positive for AIV, but Directigen and Flu OIA only detected 2/39 and NOW FLU A 1/39. Zstat and QuickVue did not detect any. Five individual cloacal swabs positive by virus isolation were negative with all five kits. In a second experiment using pools of five swabs, 26 swab pools were positive by virus isolation and 5/26 were positive by Directigen, the only kit to provide any positive results. Five cloacal swab pools were also positive by virus isolation and 1/5 was positive by Directigen; all other test kits were negative. All of these experiments were performed using the H6N2 subtype of AIV. The results are disappointing, as the kits have proven to be insensitive for detecting AIV when compared with the gold standard, virus isolation. This limits their use in diagnostic field investigations. Individual or groups of chickens could be assumed to be positive for AIV if positive by any of the kits, but a negative result with any of the kits would not prove that birds were AIV free.

Comparison of the BD Directigen Flu A+B Kit and the Abbott TestPack RSV with a multiplex RT-PCR ELISA for rapid detection of influenza viruses and respiratory syncytial virus

The Directigen Flu A+B enzyme immunoassay and the Abbott TestPack RSV enzyme immunoassay were each compared with a multiplex RT-PCR ELISA by testing 635 nasopharyngeal aspirates collected from children aged < 16 years who had been hospitalised with acute respiratory tract infection during the epidemic season 2002-2003. In this study, the sensitivity of the Directigen Flu A+B assay was unacceptably low (29.3% and 10.0%, respectively) for the detection of influenza A and B viruses. The sensitivity of the Abbott TestPack RSV assay (77.4%) was acceptable and in agreement with the multiplex RT-PCR ELISA.

H5N2 avian influenza outbreak in Texas in 2004: the first highly pathogenic strain in the United States in 20 years?

In early 2004, an H5N2 avian influenza virus (AIV) that met the molecular criteria for classification as a highly pathogenic AIV was isolated from chickens in the state of Texas in the United States. However, clinical manifestations in the affected flock were consistent with avian influenza caused by a low-pathogenicity AIV and the representative virus (A/chicken/Texas/298313/04 [TX/04]) was not virulent for experimentally inoculated chickens. The hemagglutinin (HA) gene of the TX/04 isolate was similar in sequence to A/chicken/Texas/167280-4/02 (TX/02), a low-pathogenicity AIV isolate recovered from chickens in Texas in 2002. However, the TX/04 isolate had one additional basic amino acid at the HA cleavage site, which could be attributed to a single point mutation. The TX/04 isolate was similar in sequence to TX/02 isolate in several internal genes (NP, M, and NS), but some genes (PA, PB1, and PB2) had sequence of a clearly different origin. The TX/04 isolate also had a stalk deletion in the NA gene, characteristic of a chicken-adapted AIV. By analyzing viruses constructed by in vitro mutagenesis followed by reverse genetics, we found that the pathogenicity of the TX/04 virus could be increased in vitro and in vivo by the insertion of an additional basic amino acid at the HA cleavage site and not by the loss of a glycosylation site near the cleavage site. Our study provides the genetic and biologic characteristics of the TX/04 isolate, which highlight the complexity of the polygenic nature of the virulence of influenza viruses.

Identification of influenza A virus by shell vial culture and two commercially available antigen detection methods

BACKGROUND

Effective use of amantidine and rimantidine for treating patients and for reducing transmission requires rapid diagnosis of influenza A. Rapid culture methods require 1-2 days to detect influenza A virus. Direct fluorescent antibody (DFA) staining and enzyme immunoassay (EIA) can detect influenza A antigen within 1-4 h.

OBJECTIVES

We compared DFA staining using the Bartels viral respiratory panel and the Directigen FLU-A EIA with shell vial centrifugation culture.

STUDY DESIGN

Ninety-seven fresh specimens from a variety of respiratory sources and transported from hospitals throughout the USA to our national referral laboratory were tested. A true positive was defined as culture positive or both antigen tests positive.

RESULTS

Fifteen specimens were true positive. Sensitivity with culture was 93%, EIA 67%, and DFA 47%. Specificity was excellent with all three methods: 100%, 98%, 99%. Culture detected additional viruses that can cause respiratory tract disease: herpes simplex, cytomegalovirus, respiratory syncytial, influenza B, and adenovirus. Fourteen (70%) of 20 frozen specimens previously positive for influenza A were positive on retest by EIA. Overall sensitivity of EIA compared with culture using 35 positive specimens was 69%.

CONCLUSIONS

These results suggest that the rapid EIA is useful to screen for influenza A, but that critical antigen-negative specimens should be submitted to a virology laboratory for culture for optimal sensitivity and for recovery of other viruses.

Advances in the diagnosis of respiratory virus infections

Background: Advances have been made in selecting sensitive cell lines for isolation, in early detection of respiratory virus growth in cells by rapid culture assays, in production of monoclonal antibodies to improve many tests such as immunofluorescence detection of virus antigens in nasopharyngeal aspirates, in highly sensitive antigen detections by time-resolved fluoroimmunoassays (TR-FIAs) and biotin-enzyme immunoassays (BIOTH-E), and, finally, in the polymerase chain reaction (PCR) detection of respiratory virus DNA or RNA in clinical specimens. All of these advances have contributed to new or improved possibilities for the diagnosis of respiratory virus infections.

Objectives and study design: This review summarizes our experiences during the last 15 years in the development of diagnostic tests for respiratory virus infections, and in use of these tests in daily diagnostic work and in epidemiological studies.

Results: Immunofluorescence tests based on monoclonal antibodies, all-monoclonal TR-FIAs, and biotin-enzyme immunoassays (EIAs) have about the same sensitivities and specificities. They compare well with the sensitivity of virus culture. PCR followed by liquid-phase hybridization is a sensitive method for detecting adenovirus DNA and enterovirus and rhinovirus RNA in clinical specimens. IgG EIA on paired acute and convalescent phase sera is the most sensitive serological test for respiratory virus infections and is a valuable reference method when evaluating the sensitivity of new diagnostic tests. The IgG avidity test can distinguish primary infections from re-infections at least in respiratory syncytial virus (RSV) infections. IgM antibody assays, on the other hand, had low sensitivities in our studies.

Conclusions: The choice of diagnostic methods for respiratory virus infections depends on the type and location of the laboratory, the number of specimens tested, and the previous experience of the laboratory. Virus culture, whenever possible, should be the basic diagnostic method; the results, including identification of the virus, should be available no more than 24 h later than the results of rapid diagnostic tests. In small laboratories, especially in hospitals where specimen transportation is well organized, immunofluorescence may be the best choice for antigen detection with the provision that an experienced microscopist and a good UV microscope are available. If the laboratory receives a large number of specimens and has previous experience with EIAs, then biotin-EIAs or TR-FIAs may be the most practical techniques. Their advantages include the stability of the antigens in clinical samples since intact, exfoliated epithelial cells are not required, treatment of specimens is practical, testing of large numbers of specimens is possible, and reading the printed test result is less subjective than reading fluorescence microscopy. The larger role of PCR in the diagnosis of respiratory virus infections depends on future developments such as practical methods to extract DNA or RNA and to purify the extracts from nonspecific inhibitors, plus further improvements to minimize cross-contamination. Group-specific detection of enteroviruses and rhinoviruses is an example of the potential for PCR technology. In experienced laboratories. EIA IgG antibody tests should be available. Recombinant antigens may be a useful part of such assays.

Identification of influenza A virus by shell vial culture and two commercially available antigen detection methods

BACKGROUND

Influenza continues to be a major cause of morbidity and mortality especially in the elderly and persons with underlying disease. Shell vial cell culture and antigen detection techniques may speed up diagnosis and enable better patient treatment and management.

OBJECTIVES

To compare shell vial centrifugation culture with commercially available direct fluorescence and enzyme immunoassay kits using a variety of respiratory specimens.

STUDY DESIGN

To detect influenza A virus, we compared direct fluorescent antibody (DFA) staining using the Bartels Viral Respiratory Panel and the Directigen FLU-A enzyme immunoassay (EIA) with shell vial centrifugation culture. Ninety-seven fresh specimens from a variety of respiratory sources, and transported from hospitals throughout the U.S. to our national referral laboratory, were tested.

RESULTS

Fifteen specimens were true positives: culture positive or both antigen tests positive. Sensitivity with culture was 93%, EIA 67%, and DFA 47%. Specificity was excellent with all three methods: 100%, 98%, 99%. Culture detected additional viruses that can cause respiratory tract disease: herpes simplex, cytomegalovirus, respiratory syncytial, influenza B, and adenovirus. Fourteen (70%) of 20 frozen specimens previously positive for influenza A were positive on retest by EIA. Overall sensitivity of EIA compared with culture using 35 positive specimens was 69%.

CONCLUSIONS

The rapid EIA is useful to screen for influenza A, but critical antigen-negative specimens should be submitted to a virology laboratory for culture. Shell vial cultures can provide a sensitive and universal diagnostic system for influenza A and a variety of other viruses.

Comparison of three rapid detection systems for type A influenza virus on tracheal swabs of experimentally and naturally infected birds

The present paper reports of the comparison between three rapid virus detection systems and virus isolation (VI) from pooled tracheal swabs collected from naturally and experimentally infected birds with a low pathogenicity avian influenza virus of the H7N3 subtype. The relative sensitivity, specificity and agreement (K value) were calculated for a commercial antigen capture enzyme immunoassay (AC-EIA) and for two nucleic acid detection tests, a one-step reverse transcriptase-polymerase chain reaction (RT-PCR) and a real-time RT-PCR (RRT-PCR), both targeting the M gene. The results indicate that in experimentally infected turkeys VI was positive from the pooled tracheal swabs collected from day 3 to day 10. One-step RT-PCR was able to detect influenza RNA from samples collected from day 3 to day 12, while RRT-PCR amplified influenza RNA in swabs collected from day 3 to day 15. The AC-EIA test yielded positive results between day 5 and day 10 post-infection. On field samples, the K value between the AC-EIA and VI tests was 0.82. Compared with VI, the relative sensitivity of this test was 88.9% (CI95 = 85.2-92.6) and the relative specificity was 95.7% (CI95 = 93.7-97.7). The K value between the RT-PCR and VI tests was 0.88. Compared with virus isolation, the relative sensitivity of the one-step RT-PCR was 95.6% (CI95 = 93.1-98.0) and the relative specificity was 96.3% (CI95 = 94.4-98.1). The K value between the RRT-PCR and VI tests was 0.92. Compared with virus isolation, the relative sensitivity and specificity of RRT-PCR was 93.3% (CI95 = 90.4-96.3) and 98.4% (CI95 = 97.2-99.6), respectively. Generally speaking, comparison between virus isolation, the AC-EIA test and the two nucleic acid detection methods indicated excellent agreement. Data obtained from both experimental and field study suggest a higher sensitivity of the PCR-based methods compared with the AC-EIA. The economical and practical implications of using one of the rapid tests as an alternative to VI during an avian influenza epidemic are discussed.

Evaluation of a multiplex reverse transcriptase PCR ELISA for the detection of nine respiratory tract pathogens

BACKGROUND

A multiplex reverse transcription (RT) polymerase chain reaction combined with a microwell hybridization assay (m-RT-PCR-ELISA) was previously developed to detect nine different microorganisms: enterovirus (EV), influenza virus type A (IVA) and type B (IVB), respiratory syncytial virus (RSV), parainfluenzavirus type 1 (PIV1) and type 3 (PIV3), adenovirus (AV), Mycoplasma pneumoniae (Mpn), Chlamydia pneumoniae (Cpn) in a single test. These organisms do not usually colonize the respiratory tract of humans, but, if present, it may be assumed they are involved in respiratory disease.

OBJECTIVES AND STUDY DESIGN

The m-RT-PCR-ELISA was tested on (i) culture supernatants of unknown contents, (ii) by determining the analytical sensitivity of 10-fold serial dilutions of culture supernatants and (iii) by determining clinical sensitivity in a retrospective study on 411 clinical specimens. The specimens were re-tested in parallel by m-RT-PCR-ELISA versus the gold standard culture and immunfluorescence, and versus individual RT-PCR.

RESULTS

(i) The 9-valent m-RT-PCR-ELISA shows 83% to 100% concordant results on 103 culture supernatants containing different organisms. (ii) The analytical sensitivity was as follows: higher sensitivity of the 9-valent m-RT-PCR-ELISA in comparison to culture in the cases of PIV3, IVA and IVB (factor 10) and AV and EV (factor 100), and lower sensitivity in case of RSV and PIV1 (factor 10). (iii) The agreement with the gold standard in the kappa statistic was excellent for RSV (kappa = 0.937), IVA (kappa = 0.940), very good for PIV1 (kappa = 0.914), IVB (kappa = 0.907) and satisfactory for PIV3 (kappa = 0.410). For AV, EV and Mpn the m-RT-PCR-ELISA preliminary could be qualified as very good, based on the data derived on culture supernatants. Information about the validity for Cpn is limited.

CONCLUSION

The m-RT-PCR-ELISA is a feasible, sensitive and specific method for detection of a broad spectrum of organisms. It is suitable for individual as well as epidemiological diagnosis.

Influenza in the intensive care unit

Influenza remains an important epidemic viral infection. Thousands of deaths occur and billions of dollars are spent each year with influenza-related illnesses. Morbidity and mortality are largely attributed to respiratory complications that may require intensive care unit (ICU) admission. Medical and neonatal ICUs, transplant units, chronic-care wards, and nursing homes are at increased risk for nosocomial outbreaks of influenza, which are characterized by abrupt onset and rapid spread. In this article, the authors review the current concepts, recent advances, and management strategies in influenza-associated pneumonia. Pertinent issues to the critical care practitioner are discussed in detail.

Comparison of sensitivities of virus isolation, antigen detection, and nucleic acid amplification for detection of equine influenza virus

Four seronegative foals aged 6 to 7 months were exposed to an aerosol of influenza strain A/Equi/2/Kildare/89 at 10(6) 50% egg infective doses (EID(50))/ml. Nasopharyngeal swabs were collected for 10 consecutive days after challenge. Virus isolation was performed in embryonated eggs, and the EID(50) was determined for all positive samples. The 50% tissue culture infective dose was determined using Madin-Darby canine kidney (MDCK) cells. Samples were also tested by an in vitro enzyme immunoassay test, Directigen Flu A, and by reverse transcription-PCR (RT-PCR) using nested primers from the nucleoprotein gene and a single set of primers from the matrix gene. RT-PCR using the matrix primers and virus isolation in embryonated eggs proved to be the most sensitive methods for the detection of virus. The Directigen Flu A test was the least sensitive method. The inclusion of 2% fetal calf serum in the viral transport medium inhibited the growth of virus from undiluted samples in MDCK cells but was essential for the maintenance of the virus titer in samples subjected to repeated freeze-thaw cycles.

Detection of influenza antigen with rapid antibody-based tests after intranasal influenza vaccination (FluMist)

Rapid tests for influenza antigen detection are frequently used, but it is not known how receipt of intranasal influenza vaccine affects results of these tests. We tested healthy adults who received either intranasal or intramuscular influenza vaccine. Of the 14 intranasal vaccine recipients, 7 (50%) had a direct fluorescent antibody test (DFA) result and 2 (14%) had an enzyme immunoassay (EIA) result that was positive for influenza antigen within 7 days after vaccination. No subjects had positive EIA results on day 12 or 13 after vaccination. For some intranasal vaccine recipients, rapid influenza-antigen detection tests yield positive results within 1 week after vaccination.

Influenza

Although most influenza infections are self-limited, few other diseases exert such a huge toll of suffering and economic loss. Despite the importance of influenza, there had been, until recently, little advance in its control since amantadine was licensed almost 40 years ago. During the past decade, evidence has accrued on the protection afforded by inactivated vaccines and the safety and efficacy in children of live influenza-virus vaccines. There have been many new developments in vaccine technology. Moreover, work on viral neuraminidase has led to the licensing of potent selective antiviral drugs, and economic decision modelling provides further justification for annual vaccination and a framework for the use of neuraminidase inhibitors. Progress has also been made on developing near-patient testing for influenza that may assist individual diagnosis or the recognition of widespread virus circulation, and so optimise clinical management. Despite these advances, the occurrence of avian H5N1, H9N2, and H7N7 influenza in human beings and the rapid global spread of severe acute respiratory syndrome are reminders of our vulnerability to an emerging pandemic. The contrast between recent cases of H5N1 infection, associated with high mortality, and the typically mild, self-limiting nature of human infections with avian H7N7 and H9N2 influenza shows the gaps in our understanding of molecular correlates of pathogenicity and underlines the need for continuing international research into pandemic influenza. Improvements in animal and human surveillance, new approaches to vaccination, and increasing use of vaccines and antiviral drugs to combat annual influenza outbreaks are essential to reduce the global toll of pandemic and interpandemic influenza.

Rapid diagnostic tests for influenza

In recent years, seven rapid tests for influenza have become commercially available. These tests offer the promise of making rapid influenza diagnosis much more widely available than in the past, when rapid diagnosis could be made only by fluorescent antibody staining, a demanding technique available only in advanced laboratories. Two of the rapid tests have waived status under the Clinical Laboratory Improvements Amendments of 1988. This article describes each of the seven tests and reviews English-language publications that have evaluated the performance of these tests on specimens from children. A discussion of the implications of the tests for clinical decision-making is included.

Influenza diagnosis and treatment in children: a review of studies on clinically useful tests and antiviral treatment for influenza

BACKGROUND

Prompt testing for influenza can help guide clinical management of patients with suspected influenza. Three antiviral medications, amantadine, oseltamivir and zanamivir, are approved for treatment of influenza in children. Rimantadine and ribavirin have also been used.

OBJECTIVES

To review the published evidence on clinically useful diagnostic tests and antiviral treatment for influenza virus infections in children.

METHODS

Studies published from 1966 through September 2002 were reviewed on clinical diagnosis, immunofluorescence and rapid influenza tests and on antiviral treatment of influenza virus infections among pediatric populations.

RESULTS

No studies assessed the accuracy of clinical diagnosis of influenza in children compared with viral culture. Compared with viral culture, direct immunofluorescence antibody and indirect immunofluorescence antibody tests for influenza had fair to moderate median sensitivities and high median specificities, whereas rapid influenza diagnostic tests had moderate median sensitivities and moderately high median specificities. No randomized, placebo-controlled studies were found of amantadine or rimantadine for treatment of influenza A. In a few separate controlled studies, oseltamivir, zanamivir and ribavirin each reduced symptom duration of influenza compared with placebo.

CONCLUSIONS

Additional data are needed about the accuracy of clinical diagnosis of influenza in children. Although direct immunofluorescence antibody staining, indirect immunofluorescence antibody staining and rapid tests are moderately to reasonably accurate in detecting influenza virus infections in children, physicians should use clinical judgment and local surveillance data about circulating influenza viruses when interpreting test results. Further controlled studies of the efficacy, adverse effects and emergence of antiviral resistance during treatment of influenza are needed for all of the antiviral drugs.

Practical and sensitive screening strategy for detection of influenza virus

This study evaluated the performance of Directigen FluA combined with a 3-day flu screening culture for the detection of influenza virus. This abbreviated protocol was a useful and effective tool and resulted in a substantial reduction in time, effort, and money spent, while not compromising sensitivity of influenza virus detection.

Evaluation of the Directigen FluA+B test for rapid diagnosis of influenza virus type A and B infections

Directigen FluA+B (BD Diagnostic Systems, Sparks, Md.), a new rapid test for the detection of influenza virus types A and B, was evaluated with nasopharyngeal aspirate specimens collected from 250 patients in comparison with culture and direct fluorescent antigen (DFA) detection tests. The patients studied were predominantly children, 80% being </=6 years old. Specimens negative by culture but positive by the Directigen FluA+B or DFA tests were analyzed by reverse transcription-PCR to resolve the discrepant results. The resolved sensitivity, specificity, and positive and negative predictive values of the Directigen FluA+B test for influenza virus type A were 96%, 99.6%, 96%, and 99.6%, respectively, and for influenza virus type B they were 87.5%, 96.8%, 80%, and 98%, respectively. Storage of nasopharyngeal aspirates in virus transport medium at 2 to 8 degrees C for 48 h had little adverse effect on the detection of influenza virus type A, but diagnosis of influenza virus type B is best carried out with fresh specimens. The test detected a range of human and animal influenza virus A subtypes, including the H5N1 and H9N2 viruses that recently caused human disease in Hong Kong.

Clinical and economic evaluation of rapid influenza a virus testing in nursing homes in calgary, Canada

The incremental benefits and costs of a rapid influenza A virus infection diagnostic service were studied in nursing homes in Calgary, Canada, during a single influenza season. The service was used to test 159 patients with suspected infection in a group of "experimental" nursing homes and results were compared with those for a group of "control" homes. An equal number of cases of influenza were identified in each group. Twenty-eight patients (17.6%) had confirmed cases, and 63 patients (39.6%) had probable cases. A rapid viral test result was provided much faster for patients in the experimental homes (P=.005). Both groups had the same median attack rate for influenza A virus. In experimental homes, the duration of the outbreak was shorter (P=.03), and the cost of laboratory testing and the total cost (less the hospital cost) tended to be lower (P<.2). The rapid testing service also tended to lower the overall use of resources.

Influenza pneumonia: a descriptive study

OBJECTIVE

To describe the clinical features and complications of patients hospitalized with influenza during the 1999-2000 influenza season.

METHODS

We reviewed all cases of patients with influenza admitted to a large metropolitan referral hospital during the 1999-2000 season.

RESULTS

Thirty-five adult patients (15 men and 20 women) tested positive for influenza A by direct enzyme immunoassay. A fourfold to sevenfold increase in the number of influenza cases was observed over previous years. Most patients had serious comorbid illnesses (88%), such as diabetes and chronic respiratory and heart disease. Seventeen patients developed pneumonia; these patients tended to be older (mean +/- SD, 63 +/- 13 years vs 51 +/- 19 years, respectively; p = 0.04) and had a higher incidence of chronic lung disease (41% vs 6%, respectively; p = 0.02) than the patients without pneumonia. Shortness of breath was the only symptom that distinguished patients with pneumonia from those with an upper respiratory tract illness alone. Antiviral treatment was begun 4 +/- 3 days from initiation of symptoms in patients with pneumonia and consisted of oseltamivir (35.2%), rimantadine (5.8%), or a combination of both (17.6%). Respiratory and/or blood culture results were positive in five patients (29%), Staphylococcus aureus was isolated in five patients, and Streptococcus pneumoniae was isolated in one patient. Ten of the patients with pneumonia (58.8%) were admitted to the ICU, and 5 patients (29%) died. The length of ICU stay and mechanical ventilation were 28 +/- 26 days and 21.5 +/- 20.5 days, respectively. Death in most pneumonia patients was attributed to respiratory failure.

CONCLUSION

The recognized number of hospital admissions for influenza increased fourfold to sevenfold over previous years, most likely due to the implementation of rapid diagnostic tests for influenza. Patients with signs and symptoms of influenza and shortness of breath should undergo chest radiography. Hospitalization of patients with influenza pneumonia occurred in both previously healthy and immunocompromised patients and had a high mortality. S aureus was the most common bacterial isolate in patients with influenza pneumonia. Empiric antibiotics with staphylococcal activity should be used pending culture results in patients with influenza pneumonia. The effectiveness of oseltamivir and rimantadine in treating patients with influenza pneumonia remains to be determined.

Evaluation of the Hexaplex assay for detection of respiratory viruses in children

The Hexaplex assay (Prodesse, Inc., Milwaukee, Wis.) is a multiplex reverse transcriptase (RT)-PCR assay for the detection of parainfluenza virus types 1, 2, and 3, respiratory syncytial virus (RSV) types A and B, and influenza virus types A and B. We evaluated the Hexaplex assay in comparison with conventional viral cell cultures and rapid enzyme immunoassays (EIAs) for RSV (Directigen; Becton Dickinson Inc., Cockeysville, Md.) and influenza A virus (Abbott Test Pack; Abbott Laboratories, Abbott Park, Ill.) for the detection of respiratory viruses from pediatric respiratory specimens obtained from children seen at Children's Hospital of Wisconsin from December 1997 through May 1998. A total of 363 respiratory specimens were evaluated. The tissue culture prevalence of parainfluenza virus during this period of time was low (1.1%). The sensitivity, specificity, and positive and negative predictive value of Hexaplex compared to tissue culture for the detection of parainfluenza virus were 100, 95.8, 19.0, and 100%, respectively. Only one specimen was determined to contain influenza B virus by Hexaplex; it was tissue culture negative. A specimen was considered to contain RSV or influenza A virus when it was either culture positive or culture negative but Hexaplex and EIA positive. Prior to the analysis of discrepant results, the sensitivity, specificity, and positive and negative predictive value for the detection of RSV were 91.2, 100, 100, and 98.0%, respectively, for tissue culture; 84.5, 100, 100, and 96.6% for EIA; and 98.5, 91.5, 72.8, and 99.6% for Hexaplex, respectively. The sensitivity, specificity, and positive and negative predictive value for the detection of influenza A virus prior to the analysis of discrepant results were 100, 100, 100, and 100%, respectively, for culture, 78.0, 100, 100, and 89.4% for EIA, respectively, and 95.1, 94.1, 67.2, and 99.3% for Hexaplex, respectively. Culture- and/or EIA-negative, Hexaplex-positive specimens were analyzed by a second RT-PCR assay which used primers specific for a different genomic region than that used in the Hexaplex assay. After analysis of these discrepant results, the sensitivity, specificity, and positive and negative predictive value for the detection of RSV were 74.3, 100, 100, and 93.5%, respectively, for tissue culture; 70.3, 100, 100, and 92.5% for EIA; and 98.6, 97.4, 91.2, and 99.6% for Hexaplex. The sensitivity, specificity, and positive and negative predictive value for the detection of influenza A virus were 83.3, 100, 100, and 97.4%, respectively, for tissue culture; 69.4, 100, 100, and 83.3% for EIA; and 95.8, 98.7, 92.0, and 99.3% for Hexaplex. Hexaplex is a rapid, sensitive, and specific method for the detection of the seven most common respiratory viruses in children.

A comparison of diagnostic assays for the detection of type A swine influenza virus from nasal swabs and lungs

Nasal swabs and lung samples from pigs experimentally infected with H1N1 swine influenza virus (SIV) were examined for the presence of SIV by the indirect fluorescent antibody assay, immunohistochemistry, cell culture virus isolation, egg inoculation, and 2 human enzyme immunoassays (membrane enzyme immunoassay, microwell enzyme immunoassay). Egg inoculation was considered to be the gold standard for assay evaluation. The 2 human enzyme immunoassays (EIA) and egg inoculation agreed 100% for the prechallenge nasal swabs. Agreement on SIV identification in nasal swabs with egg inoculation following challenge was considered to be good to excellent for membrane EIA (kappa = 0.85) and microwell EIA (kappa = 0.86). Agreement on SIV identification in lung tissue with egg inoculation following challenge was good to excellent for membrane EIA (kappa = 0.75), fair for microwell EIA, fluorescent antibody, and cell culture virus isolation (kappa = 0.48, 0.64, 0.62, respectively), and poor for immunohistochemistry (kappa = 0.36). No assay was 100% accurate, including the "gold standard," egg inoculation. In light of this information, it is important to consider clinical signs of disease and a thorough herd history in conjunction with diagnostic results to make a diagnosis of SIV infection.

Performance of virus isolation and Directigen Flu A to detect influenza A virus in experimental human infection

BACKGROUND

Few data exist to assess the sensitivity of different specimen types for viral detection during the course of influenza virus infection.

OBJECTIVES

This study assessed the relationships between quantitative influenza A virus replication and antigen detectability by the enzyme immunosorbent assay (EIA) Directigen Flu A in different type of samples during experimental human infection.

STUDY DESIGN

Fourteen volunteers were inoculated with influenza A virus A/Texas/36/91 (H1N1). Four specimens types were collected in sequence for quantitative isolation in cell culture and antigen testing from days 1 to 8 after inoculation.

RESULTS

Seventy-one (63%) of nasopharyngeal wash specimens were culture positive, compared to 51 (46%) of throat gargles, 51 (46%) of nasal swabs, and 27 (24%) of throat swabs. All subjects shed virus in their nasopharyngeal wash at least one day and 86% of subjects had a positive nasopharyngeal wash culture on day 2 after inoculation. The mean viral titers were highest on day 2 post inoculation for all specimen types and averaged 3.6 log10 TCID50/ml for nasal washes, 1.2 log10 TCID50/ml for throat gargles, 1.8 log10 TCID50/ml for the nasopharyngeal swabs, and 0.6 log10 TCID50/ml for the throat swabs. Mean viral titers in the nasal washes were significantly different (P<0.05) compared to other specimen types. The peak of sensitivity of EIA (compared to culture) was the second day after inoculation. Nasopharyngeal and throat swab results were combined for this analysis and considered positive by culture if positive in either or both samples. Thus, on day 2 the number of EIA positive samples relative to the number culture positive was 9/12 (75%) for nasopharyngeal wash specimens, 2/9 (22%) for throat gargles, and 7/11 (64%) for the combined throat and nasal swabs specimens.

CONCLUSIONS

Nasopharyngeal washes are the most sensitive sample type detecting influenza A virus in adults. For rapid diagnosis the Directigen Flu A is an alternative with a sensitivity compared to culture ranging between 64 and 78% if performed on nasopharyngeal specimens on day two or three after experimental infection in adults. However, if performed on other specimens or later in the course of infection the sensitivity is lower.

Isolation of influenza virus in human lung embryonated fibroblast cells (MRC-5) from clinical samples

Ninety-four pharyngeal swab samples corresponding to 94 patients with suspected influenza virus infection were inoculated in Madin-Darby canine kidney (MDCK) cells, the conventional cell system for the isolation of influenza virus, and in fibroblastic human embryo lung (MRC-5) cells, a cell system less commonly used for this purpose but one frequently used in clinical virology laboratories. Both cell preparations were treated with trypsin. Influenza virus was recovered from 15% of the samples inoculated in MDCK cells and from 18% of those inoculated in MRC-5 cells. The use of MRC-5 cells can simplify the search for respiratory viruses and would assist in the rapid detection of influenza virus during new epidemics.

Monoclonal antibodies for the direct detection of influenza-A virus by ELISA in clinical specimens from patients with respiratory infections

BACKGROUND

Monoclonal antibody technology provides antibody reagents of known specificity, high titres and unlimited availability, that form ideal reference antibodies for use in specific viral antigen-detection methods.

OBJECTIVES

To produce mouse monoclonal antibodies against antigenic sites of influenza-A virus, and evaluate their use as diagnostic reagents in a sandwich ELISA.

STUDY DESIGN

(1) Production and characterization of monoclonal antibodies against influenza-A virus; (2) application of these antibodies in an ELISA method for direct antigen detection; and (3) evaluation of the ELISA as routine procedure.

RESULTS

Four monoclonal antibodies (A1-A4) from mice immunized intranasally with influenza-A virus were selected according to their specific reactivity with either nucleoprotein or matrix protein antigens as demonstrated by Western blot analysis. These antibodies lacked haemagglutination inhibition and neutralization properties and recognized both H1N1 and H3N2 strains of influenza-A virus equally. A sandwich ELISA using unlabelled antibodies for antigen capture and biotin-labelled antibodies for antigen detection was used to analyse nasopharyngeal secretions or nasal swabs from culture-confirmed influenza-A-infected patients and comparable specimens from patients with other viral respiratory infections. Only influenza-A virus (strains H1N1 and H3N2) could be detected in samples from patients with known influenza-A and influenza-B infections, and also after re-isolation of such viruses in conventional cultures of MDCK cells or embryonated hens' eggs. The antigen-detection assay showed a diagnostic sensitivity of 100% and a specificity of 98.3% compared with conventional culture methods.

CONCLUSION

The reported ELISA appears to be a rapid and inexpensive method for diagnosis and epidemiological studies of influenza-A infections.

Evaluation of Directigen Flu A assay for detection of influenza antigen in nasal secretions of horses

The Directigen Flu A assay (Becton Dickinson, Microbiology Systems, Mississauga, Ontario, Canada) is a commercially available immunoassay designed for rapid in vitro recognition of influenza A nucleoprotein. The purpose of this study was to evaluate this assay for detection of influenza virus in nasal secretions of naturally infected horses. The assay was shown to react with representative strains of influenza virus which cause disease in horses and did not react with nasal secretions from uninfected horses kept in isolation. Between 33% and 45% of nasal secretions specimens obtained from clinically diseased horses during influenza epidemics reacted positively in the assay and 95% to 98% of horses not showing signs of disease during influenza epidemics tested negative. In contrast, influenza virus was isolated from only 7% of diseased horses using conventional techniques. Diseased horses which were positive in the Directigen assay had lower pre-exposure influenza antibody concentrations and showed more clinical signs than diseased Directigen-negative horses. This evaluation demonstrates that the Directigen Flu A assay detects influenza virus in nasal secretions of infected horses and is more sensitive than virus isolation.

Comparison of rapid diagnostic techniques for respiratory syncytial and influenza A virus respiratory infections in young children

We performed virus isolation tests for respiratory viruses on combined nasal wash-throat swab specimens collected from infants and children with acute respiratory illnesses presenting to a hospital clinic during a 3-month period of concurrent epidemics of respiratory syncytial virus (RSV) and influenza A virus (Flu A) infections. Virus isolation results were used to assess the utility of commercially available rapid diagnostic kits for these two viruses. The kits employed direct immunofluorescence (IF) of cells (Imagen for RSV and Flu A), indirect IF of cells (Baxter Bartels Microscan), and enzyme immunoassay (EIA) (Becton Dickinson Directigen for RSV and Flu A and Abbott TestPack for RSV). All testing was completed on 81 specimens from 80 subjects. Of the 81 specimens, 53 (65%) yielded a virus: RSV, 28%; Flu A, 25%; rhinovirus, 6%; and enterovirus, cytomegalovirus, herpes simplex virus, and adenovirus, 2 to 4% each. Among the tests, Bartels Microscan and Directigen Flu-A exhibited the highest sensitivities (87 and 75%) and efficiencies (94 and 94%) for RSV and Flu A, respectively. All the tests exhibited high specificity. Thus, optimal detection of RSV and Flu A among infants and children who presented to a hospital clinic required two different detection methods (IF and enzyme immunoassay) and kits from two different companies (Baxter [Bartels Microscan] and Becton Dickinson [Directigen]).