Leveraging a Large Language Model to Assess Quality-of-Care: Monitoring ADHD Medication Side Effects

Objective

To assess the accuracy of a large language model (LLM) in measuring clinician adherence to practice guidelines for monitoring side effects after prescribing medications for children with attention-deficit/hyperactivity disorder (ADHD).

Methods

Retrospective population-based cohort study of electronic health records. Cohort included children aged 6-11 years with ADHD diagnosis and ≥2 ADHD medication encounters (stimulants or non-stimulants prescribed) between 2015-2022 in a community-based primary healthcare network (n=1247). To identify documentation of side effects inquiry, we trained, tested, and deployed an open-source LLM (LLaMA) on all clinical notes from ADHD-related encounters (ADHD diagnosis or ADHD medication prescription), including in-clinic/telehealth and telephone encounters (n=15,593 notes). Model performance was assessed using holdout and deployment test sets, compared to manual chart review.

Results

The LLaMA model achieved excellent performance in classifying notes that contain side effects inquiry (sensitivity= 87.2%, specificity=86.3/90.3%, area under curve (AUC)=0.93/0.92 on holdout/deployment test sets). Analyses revealed no model bias in relation to patient age, sex, or insurance. Mean age (SD) at first prescription was 8.8 (1.6) years; patient characteristics were similar across patients with and without documented side effects inquiry. Rates of documented side effects inquiry were lower in telephone encounters than in-clinic/telehealth encounters (51.9% vs. 73.0%, p<0.01). Side effects inquiry was documented in 61% of encounters following stimulant prescriptions and 48% of encounters following non-stimulant prescriptions (p<0.01).

Conclusions

Deploying an LLM on a variable set of clinical notes, including telephone notes, offered scalable measurement of quality-of-care and uncovered opportunities to improve psychopharmacological medication management in primary care.

Rapid model-guided design of organ-scale synthetic vasculature for biomanufacturing

Our ability to produce human-scale bio-manufactured organs is critically limited by the need for vascularization and perfusion. For tissues of variable size and shape, including arbitrarily complex geometries, designing and printing vasculature capable of adequate perfusion has posed a major hurdle. Here, we introduce a model-driven design pipeline combining accelerated optimization methods for fast synthetic vascular tree generation and computational hemodynamics models. We demonstrate rapid generation, simulation, and 3D printing of synthetic vasculature in complex geometries, from small tissue constructs to organ scale networks. We introduce key algorithmic advances that all together accelerate synthetic vascular generation by more than 230 -fold compared to standard methods and enable their use in arbitrarily complex shapes through localized implicit functions. Furthermore, we provide techniques for joining vascular trees into watertight networks suitable for hemodynamic CFD and 3D fabrication. We demonstrate that organ-scale vascular network models can be generated in silico within minutes and can be used to perfuse engineered and anatomic models including a bioreactor, annulus, bi-ventricular heart, and gyrus. We further show that this flexible pipeline can be applied to two common modes of bioprinting with free-form reversible embedding of suspended hydrogels and writing into soft matter. Our synthetic vascular tree generation pipeline enables rapid, scalable vascular model generation and fluid analysis for bio-manufactured tissues necessary for future scale up and production.

Anxiety and Depression Treatment in Primary Care Pediatrics

BACKGROUND AND OBJECTIVES

Primary care pediatricians (PCP) are often called on to manage child and adolescent anxiety and depression. The objective of this study was to describe PCP care practices around prescription of selective serotonin reuptake inhibitors (SSRI) for patients with anxiety and/or depression by using medical record review.

METHODS

We identified 1685 patients who had at least 1 visit with a diagnosis of anxiety and/or depression in a large primary care network and were prescribed an SSRI by a network PCP. We randomly selected 110 for chart review. We reviewed the visit when the SSRI was first prescribed (medication visit), immediately previous visit, and immediately subsequent visit. We abstracted rationale for prescribing medication, subspecialist involvement, referral for psychotherapy, and medication monitoring practices.

RESULTS

At the medication visit, in 82% (n = 90) of cases, PCPs documented reasons for starting an SSRI, most commonly clinical change (57%, n = 63). Thirty percent (n = 33) of patients had documented involvement of developmental-behavioral pediatrics or psychiatry subspecialists at 1 of the 3 visits reviewed. Thirty-three percent (n = 37) were referred to unspecified psychotherapy; 4% (n = 4) were referred specifically for cognitive behavioral therapy. Of 69 patients with a subsequent visit, 48% (n = 33) had documentation of monitoring for side effects.

CONCLUSIONS

When prescribing SSRIs for children with anxiety and/or depression, PCPs in this network documented appropriate indications for starting medication and prescribed without subspecialist involvement. Continuing medical education for PCPs who care for children with these conditions should include information about evidence-based psychotherapy and strategies for monitoring potential side effects.

Lessons from Developing Multimedia Learning Materials for the Digital Generation

Recognizing that traditional textbooks on need-driven health technology innovation were increasingly misaligned with the needs of today's undergraduate biomedical engineering students and the faculty who teach them, we initiated an effort to develop new learning materials for this audience. To guide our efforts, we conducted literature searches on best practices in the development of online content and engaging digital learners (primarily Gen-Z). We further held a series of discussions with biomedical engineering students and instructors at universities across the United States. This input led us to the development of a set of modular, online, multimedia learning materials specifically designed for the new generation of undergraduate learners. In this article, we present the key decisions that helped shape the project. We also share the results of feedback surveys and focus groups that shed light on how the materials have been preliminarily received. Finally, we reflect on challenges, opportunities, and lessons from this project that may be helpful to other initiatives focused on the creation of multimedia content for the digital generation.

Large-Scale Production of Wholly Cellular Bioinks via the Optimization of Human Induced Pluripotent Stem Cell Aggregate Culture in Automated Bioreactors

Combining the sustainable culture of billions of human cells and the bioprinting of wholly cellular bioinks offers a pathway toward organ-scale tissue engineering. Traditional 2D culture methods are not inherently scalable due to cost, space, and handling constraints. Here, the suspension culture of human induced pluripotent stem cell-derived aggregates (hAs) is optimized using an automated 250 mL stirred tank bioreactor system. Cell yield, aggregate morphology, and pluripotency marker expression are maintained over three serial passages in two distinct cell lines. Furthermore, it is demonstrated that the same optimized parameters can be scaled to an automated 1 L stirred tank bioreactor system. This 4-day culture results in a 16.6- to 20.4-fold expansion of cells, generating approximately 4 billion cells per vessel, while maintaining >94% expression of pluripotency markers. The pluripotent aggregates can be subsequently differentiated into derivatives of the three germ layers, including cardiac aggregates, and vascular, cortical and intestinal organoids. Finally, the aggregates are compacted into a wholly cellular bioink for rheological characterization and 3D bioprinting. The printed hAs are subsequently differentiated into neuronal and vascular tissue. This work demonstrates an optimized suspension culture-to-3D bioprinting pipeline that enables a sustainable approach to billion cell-scale organ engineering.

Exercise Capacity and Training Programs in Paediatric Fontan Patients: A Systematic Review

Background

Exercise training programs can effectively enhance exercise capacity in adults with congenital heart disease, including Fontan patients. However, few studies have explored the impact of exercise training exclusively on paediatric Fontan cohorts. This study systematically reviews exercise capacity in paediatric Fontan patients and the impact of training programs on their cardiovascular health.

Methods

Medline and Embase were searched for articles published between January 1990 and November 2021. Studies were included in which data could be analyzed discretely for patients who had undergone the Fontan procedure and were ≤20 years old at the time of study. Cardiopulmonary exercise parameters were extracted from all studies, and training protocols were collected from training programs.

Results

The studies demonstrated that Fontan patients exhibit significantly diminished peak exercise capacity relative to healthy peers. We identified 9 training programs that exclusively studied Fontan patients ≤20 years. The programs ranged from 6 weeks to 12 months in duration, with 8 programs incorporating aerobic activity and 1 focused only on inspiratory muscle training. At least 1 measure of maximal or submaximal exercise capacity improved significantly within each program in which statistical analysis was performed, with no reported adverse events. There were 2 additional training programs in which the patients were predominantly (>65%), but not exclusively, Fontan patients.

Conclusions

Overall, the results indicate that exercise training programs can safely and effectively improve at least 1 measure of exercise capacity in paediatric Fontan patients.

Immunobiology of Norwalk virus

Clinical immunity to Norwalk virus in inoculated human volunteers appears to be unusual for gastroenteritis viruses, as certain individuals are repeatedly ill on long-term virus rechallenge and others remain persistently well. In these volunteers there is a paradoxical inverse correlation between the prechallenge serum (and jejunal fluid) Norwalk antibody level (measured by radioimmunoassay) and resistance to illness, suggesting that non-immunological factors, perhaps genetic, may be important in determining resistance. Most reported naturally occurring Norwalk disease outbreaks in developed nations also show that humoral antibody fails to correlate with immunity to infection. The unusual pattern of clinical immunity to Norwalk virus indicates a need for caution in the development of vaccines against this agent as well as a need for additional information on its immunobiological characteristics. The virus is known to contain a single protein, like the caliciviruses. Recently we have found evidence for at least a one-way serological cross-relatedness between Norwalk virus and human calicivirus. Twelve of 20 paired sera from ill patients in outbreaks due to calicivirus strain UK4 seroconverted to Norwalk virus by radioimmunoassay and two of eight paired sera from UK2 outbreaks showed seroconversion. Future studies of outbreaks caused by various calicivirus strains should be designed to correlate acute-phase serum antibody titres to Norwalk virus with clinical susceptibility and immunity to infection.

Immune responses and protection obtained with rotavirus VP6 DNA vaccines given by intramuscular injection

Intramuscular (i.m.) injection of murine VP6 DNA vaccines raised high titers of rotavirus-specific serum IgG and IgA antibodies in BALB/c mice. A Th1-like antibody response was generated based on the ratio of serum IgG2a to IgG1 antibodies. Rotavirus-specific serum IgA but not fecal IgA was detected in mice prior to rotavirus challenge. Partial protection against rotavirus challenge was achieved as measured by reduction of rotavirus antigen shedding in feces. A similar level of protection was found with a bovine rotavirus VP6 DNA vaccine against a murine rotavirus challenge, suggesting that heterologous protection can be obtained by immunizing with VP6 DNA vaccines. We did not directly test for cytotoxic T lymphocyte (CTL) activity, but in vivo depletion of CD8+ T cells in mice immunized with a murine VP6 DNA vaccine did not significantly change the duration of virus shedding or the pattern of protection obtained. This finding suggested that CD8+ CTL activity was not essential for the partial protection we obtained by i.m. immunization of mice with VP6 DNA vaccines.

Human astrovirus isolation and propagation in multiple cell lines

Laboratory adapted human astrovirus serotypes 1 through 7 were tested for growth in 15 human, 7 simian, and 10 other non-primate mammalian cell lines. Propagation of all seven serotypes was successful in the human cell lines Caco-2, T84, HT-29, and in the African green monkey kidney cell line MA-104. Both primary and secondary African green monkey kidney cells were more effective than Rhesus monkey kidney cells for cultivation of astrovirus. Except for human foreskin cells, all of the other human and simian cell lines supported growth of at least one astrovirus serotype. The only non-primate cell line that permitted sustained passage of astroviruses was the BHK-21 (C13) cell line for astrovirus serotype 2. Seventeen human stool specimens that had previously been shown to be astrovirus positive by ELISA were cultured in Caco-2, T84, HT-29, SK-CO-1, PLC/PRF/5, MA-104, and VERO cells. Caco-2 cells (13 isolates), T84 cells (12 isolates) and PLC/PRF/5 cells (12 isolates) were the cell lines most effective for isolation of human astroviruses from clinical stool specimens. By immunofluorescent staining of infected cells, culturing of the same 17 specimens in shell vials for 18 h was positive for astroviruses in all 17 specimens in Caco-2 cells, 12 in T84 cells, and 7 in PLC/PRF/5 cells. Shell vial assay is suitable as a rapid and sensitive culture technique for detection of astroviruses in clinical specimens.

Immunoglobulin M antibody test to detect genogroup II Norwalk-like virus infection

Sera obtained from adult volunteers inoculated with genogroup II Norwalk-like viruses (NLVs), Hawaii virus, and Snow Mountain virus and from patients involved in outbreaks of gastroenteritis were tested for genogroup II NLV Mexico virus-specific immunoglobulin M (IgM) by use of a monoclonal antibody, recombinant Mexico virus antigen (rMXV)-based IgM capture enzyme-linked immunosorbent assay (ELISA). Sera from genogroup I Norwalk virus (NV)-inoculated volunteers and from patients involved in a genogroup I NLV outbreak were also tested. In sera from those infected with genogroup I NV or NLVs in volunteer and outbreak studies, only 3 of 25 were rMXV IgM positive; in contrast, 24 of 25 were IgM positive for recombinant NV (rNV). In sera from those infected with genogroup II NLVs in volunteer and outbreak studies, 28 of 47 were rMXV IgM positive and none were IgM positive for rNV, showing the specificity of each IgM test for its respective genogroup. In an outbreak of gastroenteritis not characterized as being of viral etiology but suspected to be due to NV, 7 of 13 persons had IgM responses to rMXV, whereas none had IgM responses to rNV, thus establishing the diagnosis as genogroup II NLV infection. The rMXV-based IgM capture ELISA developed is specific for the diagnosis of genogroup II NLV infections.

Immunity obtained by gene-gun inoculation of a rotavirus DNA vaccine to the abdominal epidermis or anorectal epithelium

We have previously shown that gene-gun delivery of murine rotavirus DNA vaccines to the epidermis induced protection against rotavirus challenge in mice. In this study, we used a rotavirus group antigen (VP6)-specific DNA vaccine to compare epidermal immunization with immunization to the anorectal epithelium for efficacy in inducing protective immunity. The vaccine was administered into cells of the abdominal epidermis or anorectal epithelium of adult BALB/c mice with an Accell gene-gun (PowderJect, Inc). Vaccines administered by either route elicited rotavirus-specific ELISA antibodies and analysis of the IgG subtypes indicated Th2-type responses were generated by both routes of administration, in contrast to Th1-type responses generated by live rotavirus. Protection against virus challenge was obtained in mice inoculated by either route, as shown by significant reduction of virus excreted in stools. The protection obtained by immunization of the anorectal epithelium was greater than that for epidermal immunization at the same vaccine dose. These results suggest that mucosal immunization of DNA vaccines may be an effective means to generate protective immunity against mucosal pathogens.

Immune responses and protection obtained by oral immunization with rotavirus VP4 and VP7 DNA vaccines encapsulated in microparticles

Protective immune responses in mice were obtained after oral immunization with rotavirus DNA vaccines encapsulated in poly(lactide-co-glycolide) (PLG) microparticles. The DNA vaccines used encoded outer capsid proteins VP4 and VP7; proteins that are the basis for rotavirus serotyping and the generation of virus neutralizing antibodies. One dose of vaccine was given to BALB/c mice by oral gavage (75 microg DNA/mouse). Rotavirus-specific serum antibodies and intestinal IgA antibodies were detectable by 6 weeks postimmunization. After challenge with homologous murine rotavirus at 12 weeks postimmunization, fecal rotavirus antigen was reduced significantly in immunized mice compared with controls. Protective immunity also was generated by oral delivery of unencapsulated VP 7 DNA vaccine but to a lesser degree. These results demonstrate that the oral route is effective for generating protective immune responses with rotavirus DNA vaccines targeting neutralization antigens.

Astrovirus infection in South Africa: a pilot study

Astroviruses have been shown to be important aetiological agents associated with gastroenteritis in children, as have rotaviruses and the enteric adenoviruses. However, no inclusive studies have been conducted in South Africa to allow a comparison of the relative roles of these different viral agents. In this study, stool specimens were obtained between 1991 and 1993 from 225 young children with acute gastro-enteritis. These were examined for the presence of astroviruses using a monoclonal antibody-based ELISA, and for rotaviruses and enteric adenoviruses using commercially available kits. A control group of 56 infants and young children without symptoms of diarrhoeal illness was included in the study. Astroviruses were detected in 7% of the stools compared with 20% infected with rotaviruses and only 3% infected with enteric adenoviruses. In the control group, one specimen each had astrovirus or adenovirus and two shed rotaviruses. The astrovirus prevalence observed in this study is similar to that reported in other developing communities. Rotavirus and astrovirus infections were more prevalent in the autumn and early winter than in other seasons. Astrovirus and rotavirus infections predominated in children between 3 and 22 months of age.

Protective immunity induced by oral immunization with a rotavirus DNA vaccine encapsulated in microparticles

DNA vaccines are usually given by intramuscular injection or by gene gun delivery of DNA-coated particles into the epidermis. Induction of mucosal immunity by targeting DNA vaccines to mucosal surfaces may offer advantages, and an oral vaccine could be effective for controlling infections of the gut mucosa. In a murine model, we obtained protective immune responses after oral immunization with a rotavirus VP6 DNA vaccine encapsulated in poly(lactide-coglycolide) (PLG) microparticles. One dose of vaccine given to BALB/c mice elicited both rotavirus-specific serum antibodies and intestinal immunoglobulin A (IgA). After challenge at 12 weeks postimmunization with homologous rotavirus, fecal rotavirus antigen was significantly reduced compared with controls. Earlier and higher fecal rotavirus-specific IgA responses were noted during the peak period of viral shedding, suggesting that protection was due to specific mucosal immune responses. The results that we obtained with PLG-encapsulated rotavirus VP6 DNA are the first to demonstrate protection against an infectious agent elicited after oral administration of a DNA vaccine.

Detection of Norwalk virus and other genogroup 1 human caliciviruses by a monoclonal antibody, recombinant-antigen-based immunoglobulin M capture enzyme immunoassay

Sera obtained from two groups of adult volunteers infected with Norwalk virus (NV) and two groups of patients involved in two natural outbreaks were tested for NV-reactive immunoglobulin M (IgM) by use of a monoclonal antibody, recombinant-antigen-based IgM capture enzyme immunoassay (EIA). No NV-reactive IgM was detected in the preinoculation sera of 15 volunteers, and 14 of 15 showed NV-reactive antibodies postinfection with NV. All of the volunteers showed IgG seroconversion to NV. In the outbreak studies, all 9 persons in one outbreak and 19 of 24 in another outbreak had NV-reactive IgM. In the first outbreak, only three of nine seroconverted to NV, which was likely due to late collection of acute-phase sera. In the second outbreak, 21 of 24 showed IgG seroconversion to NV. Sequencing of viruses isolated from five stool samples selected from those in the second outbreak showed that they were human calicivirus (HuCV) genogroup 1 viruses related, but not identical, to NV. In the volunteer studies, NV-reactive IgM was first detected 8 days postinoculation. The time of development of NV-reactive IgM antibodies in natural outbreaks was estimated to be similar to that found in the volunteer studies. Sera from three Hawaii virus-infected volunteers, four Snow Mountain virus patients, and 80 healthy individuals were negative for NV-reactive IgM, indicating test specificity for HuCV genogroup I infections. This capture IgM EIA is suitable for diagnosis of NV and other HuCV genogroup I infections and is especially useful when sera and fecal samples have not been collected early in the course of an outbreak.

Protective immunity induced by rotavirus DNA vaccines

It is estimated that Group A rotavirus diarrhea causes as many as one million deaths per year in children worldwide, and effective vaccines will be essential for their control. Plasmid DNA vaccines encoding murine rotaviral proteins VP4, VP6, or VP7 were tested in adult BALB/c mice for their ability to induce immune responses and provide protection against rotavirus challenge. The vaccines were administered by inoculation into cells of the epidermis with an Accell gene gun. (Auragen, Inc., Middleton, WI, USA). Each vaccine elicited rotavirus-specific serum antibodies as measured by ELISA. Virus neutralizing antibodies were detected in mice receiving plasmid DNAs encoding for outer capsid proteins VP4 and VP7, but not for VP6, an inner capsid protein, and all of the vaccines generated virus-specific CTL responses. Each vaccine was effective in protecting mice against infection after homotypic rotavirus (100 ID50) challenge, showing reductions (P < 0.0002) in viral excretion measured over a 9 day period. Increased rotavirus-specific intestinal IgA antibodies were seen in vaccinated mice after rotavirus challenge, particularly in mice that received the VP6 DNA vaccine. This suggests that intracellular IgA-mediated neutralization may be involved in protective immunity induced by the VP6 DNA vaccine, and may represent a new mechanism for protection by DNA vaccines.

Protection against rotavirus infections by DNA vaccination

DNA vaccines encoding for murine rotavirus proteins VP4, VP6, or VP7 were tested in adult BALB/c mice for their ability to induce immune responses and protect against rotavirus challenge. A gene gun was used to inoculate vaccines into the epidermis. Rotavirus-specific serum antibodies, as measured by ELISA, and virus-specific cytotoxic T lymphocyte responses were generated by each of the three vaccines, but virus-neutralizing antibodies were detected only in mice that were inoculated with DNA vaccines encoding for VP4 and VP7. Efficacy of the vaccines was determined by challenge with 100 ID50 of homotypic rotavirus. Each of the three vaccines was effective in protecting mice against infection after rotavirus challenge as determined by reduction (P < .001) in virus excretion in mice receiving the DNA vaccines. These results demonstrate that DNA vaccination has potential as a new approach for control of rotavirus infections.

Epidemiology of diarrhea among expatriate residents living in a highly endemic environment

OBJECTIVE

To determine the etiology of diarrhea among expatriate residents living in a developing country and identify risk factors for travelers' diarrhea that are difficult to evaluate in tourist populations.

DESIGN

Clinic based case-control study.

SETTING

Primary care travel medicine clinic in Kathmandu, Nepal.

PARTICIPANTS

A total of 69 expatriate residents with diarrhea, compared with 120 tourists with diarrhea, and 112 asymptomatic resident and tourist controls, selected systematically during a 1-year period.

MAIN OUTCOME MEASURES

Risk factors for diarrhea assessed by questionnaire and pathogen prevalence assessed by microbiologic analysis of stool specimens.

RESULTS

The dominant risk factors for diarrhea among expatriate residents included younger age (P = .003), shorter duration of stay in Nepal (P < .001), and eating out in restaurants (P = .01). Eating raw vegetables, salads, fresh fruit, or ice served in restaurants was not significantly associated with diarrhea. Longer duration of residence was linearly correlated with protection. Enteric pathogens were identified in 44 (64%) of 69 residents with diarrhea compared with 100 (83%) of 120 tourists with diarrhea, with enterotoxigenic Escherichia coli, Campylobacter, and Shigella predominant for both groups. Pathogens were also found in stools from 32 (37%) of 87 asymptomatic resident controls and 13 (52%) of 25 tourist controls. The attack rate of diarrhea among expatriates was estimated to be 49% (95% confidence interval, 37% to 61%) per month during the first 2 years of residence. The highest-risk months were April through July.

CONCLUSIONS

Diarrhea among expatriates in a highly endemic environment is a persistent risk. The extremely high prevalence of enteric pathogens among asymptomatic persons reflects widespread exposure. The most important risk factors for travellers' diarrhea are difficult to modify, including younger age, duration of stay, eating in restaurants, and seasonality. Preventive dietary recommendations may not be fully protective, suggesting that pretravel advice should emphasize empiric treatment in addition to strategies to avoid exposure.

DNA vaccines against rotavirus infections

Plasmid DNA vaccines encoding for murine rotaviral proteins VP4, VP6, and VP7 were tested in adult BALB/c mice for their ability to induce immune responses and provide protection against rotavirus challenge. Serum antibodies were measured by virus neutralization and by ELISA. Cellular immunity was assessed by measuring cytotoxic T cell (CTL) responses. The vaccines were administered by inoculation into cells of the epidermis with an Accell gene gun (Auragen, Inc., Middleton, WI, USA). Each of the three vaccines elicited rotavirus-specific serum antibodies as measured by ELISA. Virus neutralizing antibodies were detected in mice receiving DNA vaccines encoding for VP4 and VP7, but not in those which received the plasmid encoding for VP6. Vaccines encoding for VP4, VP6, or VP7 generated virus-specific CTL responses in recipient mice. Efficacy of the vaccines was determined by challenge with homotypic rotaviruses. Each of the three vaccines was effective in protecting mice against infection after rotavirus (100 ID50) challenge. Significant reductions (p < 0.0002, analysis of variance) in viral excretion measured over a 9 day period were seen in mice receiving the DNA vaccines compared with mice that received control plasmids.

The changing epidemiology of astrovirus-associated gastroenteritis: a review

Our understanding of the epidemiology of astrovirus-associated gastroenteritis has changed markedly with each improvement in detection method. In early surveys based on electronmicroscopy (EM), astroviruses appeared to be a rare cause of gastroenteritis, being found in fewer than 1% of children with diarrhea, usually in small outbreaks of disease and primarily during the winter season. The development and use of monoclonal antibodies and enzyme immunoassays (EIA) to detect astroviruses led to reports of a higher prevalence (2.5%-9%) of astrovirus infection among patients hospitalized with diarrhea. Astroviruses appeared second only to rotaviruses as a cause of hospitalization for childhood viral gastroenteritis. Studies based on EIA detection of astroviruses indicate that astroviruses are common causes of diarrhea in children worldwide, and that most children are infected during their first two years of life. The elderly and the immunocompromised represent high-risk groups as well. The observations that newborns monitored prospectively rarely have repeat disease and that the rate of detection decreases with increasing age suggest that immunity to astroviruses, as immunity to rotaviruses, may develop early in life. The cloning and sequencing of astroviruses have led to more sensitive assays to detect the viruses by reverse transcription, polymerase chain reaction (RT-PCR). Application of RT-PCR for detection of astroviruses in children in day-care centers showed a marked increase in the detected prevalence of astrovirus-associated diarrhea, the rate of asymptomatic infection, and the duration of shedding of virus among those infected, when compared with studies that used other methods. As with rotaviruses, neither the mode of transmission nor the reservoir of astrovirus infection has been identified. Both immune and molecular-based assays to detect astrovirus serotypes indicate that serotype 1 is most common worldwide, although the predominant serotypes may vary by region and time. In the absence of obvious strategies to prevent astrovirus-associated diarrhea, vaccines might be considered if further studies establish that the disease burden would render such a vaccine cost-effective.

Monoclonal antibodies for detection of Norwalk virus antigen in stools

Monoclonal antibodies against the prototype 8FIIa strain of Norwalk virus were prepared and applied to an enzyme immunoassay (EIA) for detecting Norwalk virus in stool specimens. The monoclonal antibodies immunoprecipitated a 58-kDa protein which had been produced by in vitro transcription-translation of Norwalk virus cloned cDNA, and they reacted by EIA with recombinant Norwalk virus capsid protein at a sensitivity level of 1 ng/ml. The EIA detected virus in all tested samples from 15 different Norwalk virus-infected volunteers. No cross-reactions were seen in stools containing other caliciviruses or in stools containing rotaviruses, astroviruses, or enteric adenoviruses.

Comparison of three monoclonal antibody-based enzyme immunoassays for detection of herpes simplex virus in clinical specimens

Three commercial monoclonal antibody-based enzyme immunoassays (Herpchek, IDEIA HSV and SureCell HSV) for detection of herpes simplex virus antigen were compared with isolation of virus in cell cultures. A total of 51 culture positive and 49 culture negative consecutively collected specimens that had been stored at -70 degrees C for a period of up to ten months were used in the study. Herpchek, IDEIA HSV and SureCell HSV assays gave a sensitivity of 88.2%, 82.4% and 47.1% respectively, and a specificity of 95.9%, 93.9% and 83.7% respectively compared to cell culture. A blocking antibody test showed that two culture negative specimens contained herpes simplex virus-specific antigens. If these two specimens were considered to be true positive, Herpchek, IDEIA HSV and SureCell HSV assays had a sensitivity of 88.7%, 83.0% and 47.2%, and a specificity of 100%, 97.9% and 85.1% respectively. The positive predictive value (using the resolved sample results) for Herpchek, IDEIA HSV and SureCell HSV was 100%, 97.8% and 78.1% respectively, and the negative predictive value 88.7%, 83.6% and 58.8% respectively. These results demonstrated that Herpchek and IDEIA HSV are sensitive and highly specific assays. Results could be obtained in less than five hours after receipt of specimens. SureCell HSV gave results in 15 minutes, but both the sensitivity and specificity were too low for this test to be considered as a substitute for culture.

Analysis of astrovirus serotype 1 RNA, identification of the viral RNA-dependent RNA polymerase motif, and expression of a viral structural protein

We report the results from sequence analysis and expression studies of the gastroenteritis agent astrovirus serotype 1. We have cloned and sequenced 5,944 nucleotides (nt) of the estimated 7.2-kb RNA genome and have identified three open reading frames (ORFs). ORF-3, at the 3' end, is 2,361 nt in length and is fully encoded in both the genomic and subgenomic viral RNAs. Expression of ORF-3 in vitro yields an 87-kDa protein that is immunoprecipitated with a monoclonal antibody specific for viral capsids. This protein comigrates with an authentic 87-kDa astrovirus protein immunoprecipitated from infected cells, indicating that this region encodes a viral structural protein. The adjacent upstream ORF (ORF-2) is 1,557 nt in length and contains a viral RNA-dependent RNA polymerase motif. The viral RNA-dependent RNA polymerase motifs from four astrovirus serotypes are compared. Partial sequence (2,018 nt) of the most 5' ORF (ORF-1) reveals a 3C-like serine protease motif. The ORF-1 sequence is incomplete. These results indicate that the astrovirus genome is organized with nonstructural proteins encoded at the 5' end and structural proteins at the 3' end. ORF-2 has no start methionine and is in the -1 frame compared with ORF-1. We present sequence evidence for a ribosomal frameshift mechanism for expression of the viral polymerase.

Cloning and characterization of human astrovirus immunoreactive epitopes

We report the cloning of antigenic, protein-coding regions of human astrovirus serotype 1 that appear to be common to most, if not all, serotypes of human astrovirus. Screening of lambda gt11 libraries identified three different but overlapping clones (A43, A35, and A1) and one independent clone (A14) that reacted with serum from a rabbit repeatedly immunized with purified astrovirus particles but not with its preimmunization serum. These clones were shown to be astrovirus specific. Of note, a radiolabeled probe representing the immunoreactive clones A43-A35-A1 hybridized exclusively to the 7.2-kb astrovirus genomic RNA, while a clone A14-specific probe hybridized with both the genomic and the 2.8-kb astrovirus subgenomic RNAs. This suggests that the immunoreactive epitopes, selected by antiserum to purified astrovirus particles, are encoded by the subgenomic RNA as well as other regions of the genomic RNA.

Etiology of acute diarrhea among United States military personnel deployed to South America and west Africa

A study of acute diarrhea was conducted from 1985 to 1987 among U.S. military personnel participating in routine shipboard exercises in South America and West Africa and ground troops deployed to coastal Ecuador. An enteropathogen was identified in 146 (51%) of 289 acute cases of diarrhea. Enterotoxigenic Escherichia coli, found in 50 (17%) patients with diarrhea, was the most commonly identified enteropathogen. Viral enteropathogens were also found in a high percentage of acute cases of diarrhea: rotavirus was detected in 11% of the patients and Norwalk virus infection in 10%. Most enteric pathogens were acquired in equal frequencies in South America and West Africa, except for rotavirus infection which was identified more often in West Africa and enteroaggregative E. coli infection which was identified more often in South America. Bacterial enteropathogens were frequently resistant to trimethoprim/sulfamethoxazole, but no resistance to quinolone drugs was observed, indicating that quinolone drugs have become important agents for the treatment of diarrhea in South America and West Africa.

Detection of Norwalk virus in stool specimens by reverse transcriptase-polymerase chain reaction and nonradioactive oligoprobes

A reverse transcriptase (RT)-polymerase chain reaction (PCR)-oligoprobe (OP), or RT-PCR-OP, method was developed for the detection of the Norwalk virus, which causes acute, epidemic gastroenteritis, in stool specimens. The Norwalk virus genome regions encoding the following two proteins were amplified by RT-PCR: the RNA polymerase (260-bp product) and a putative immunogenic protein (224-bp product). The resulting DNA fragments (amplicons) were hybridized to a digoxigenin-labeled internal OP specific to each amplicon. The detection limit of Norwalk virus, as determined by the endpoint of RT-PCR amplification for serially diluted, positive stool specimens, was similar to the actual virion titer as estimated by electron microscopy and at least 100-fold greater than the titer determined by radioimmunoassay (RIA). The RT-PCR-OP assay was specific for Norwalk virus and negative for other enteric viruses, including human and animal caliciviruses, hepatitis E virus, Snow Mountain agent, astroviruses, 16 human enteroviruses, and 5 human rotaviruses. Components of fecal specimens that interfere with RT-PCR were removed successfully by Sephadex G-200 gel chromatography. Of 20 stool specimens from human volunteers that were positive for Norwalk virus by RIA, a specific RT-PCR-OP result was obtained in 95% (19 of 20) of the samples by using the immunogenic protein primers and 75% (15 of 20) by using the polymerase primers. Twenty-six stool specimens from asymptomatic children and adults were negative by the Norwalk virus RT-PCR-OP. RT-PCR-OP detected Norwalk virus in the 4 of 21 coded fecal specimens that were also positive by enzyme immunoassay. Two samples that were positive by RIA or enzyme immunoassay were negative by RT-PCR, perhaps because viral RNA was not present or RT-PCR inhibitors were not adequately removed.

Astrovirus-associated diarrhea among Guatemalan ambulatory rural children

Fecal excretion of astroviruses was monitored in 321 children, 0 to 3 years old, living in the rural highlands of Guatemala. During the longitudinal study, from February 1987 to February 1989, we examined 5,000 stool specimens, including 1,805 collected during 1,369 episodes of diarrhea, 830 collected during the convalescent week, and 216 and 244 collected 2 weeks and 1 week, respectively, before the onset of diarrhea. Routine specimens were taken once a month from every child who had been free from diarrhea for at least three consecutive weeks. Of the children, 124 (38.6%) excreted astroviruses during the study. In total, we identified 184 infections by astroviruses. Of the samples collected 2 weeks and 1 week before the initiation of symptoms, 0.9 and 4.9%, respectively, were positive, while 7.3% of the diarrhea episodes were associated with astroviruses. Of the convalescent specimens, 3.4% were shown to be positive; 2.4% of the 1,905 specimens taken in diarrhea-free periods contained astroviruses. Infections by other potential enteropathogens were documented in 54 and 65% of the asymptomatic and symptomatic astrovirus infections, respectively. Diarrhea associated with astroviruses alone had a median duration of 5 days and was associated with vomiting in 8.6%, with fever in 17.1%, with dehydration in 5.7%, and with loss of appetite in 34.3% of the episodes. Diarrhea due to astroviruses was accompanied by negative changes in weight gain. Astrovirus diarrhea contributes to the high morbidity observed in young children living under poor conditions and has a deleterious effect on their nutritional status.

Detection of astrovirus in pediatric stool samples by immunoassay and RNA probe

Two new astrovirus assays, a rapid biotin-avidin enzyme immunoassay (EIA) and RNA probe hybridization, were developed and compared with an established astrovirus assay, an indirect EIA, and immune electron microscopy. Sensitivity and specificity were evaluated by using a screening panel of 22 astrovirus-positive and 305 astrovirus-negative fecal specimens. The biotin-avidin assay was equivalent in performance to the reference indirect assay, and both could detect about 10 ng of viral protein. Although the probe was more sensitive than either EIA and could detect higher dilutions of virus in tissue culture and stool specimens, it did not detect more astrovirus-positive fecal specimens. Of the 22 astrovirus-positive specimens detected by the EIAs, 20 were confirmed by immune electron microscopy with hyperimmune rabbit antiserum. To determine the usefulness of EIAs for large epidemiologic studies, EIAs were used to screen 1,289 stool specimens from three studies of children with and without diarrhea. Astrovirus was detected in 3.5% of specimens from children with diarrhea and 1.9% of specimens from those without diarrhea. Our results indicate that the biotin-avidin EIA is an efficient, sensitive, and specific method for routinely screening large numbers of fecal samples and that its application in epidemiologic studies may yield higher rates of astrovirus infection than have been found previously by other methods.

Astrovirus and adenovirus associated with diarrhea in children in day care settings

The relative importance of astrovirus and adenoviruses as etiologic agents of diarrhea among children in day care was examined. Stool specimens from this prospective study were screened for both astrovirus and adenovirus hexon with two new indirect double-antibody assays and for enteric adenoviruses with an EIA specific for serotypes 40 and 41. Astrovirus was detected in a significantly greater percentage of children with diarrhea (4%, 21/524) than of those without (less than 1%, 1/138) (P less than .05); however, no difference between such such children with adenovirus infections was found (8%, 43/565, and 8%, 10/129, respectively). Overall, 30% (13/43) of all adenovirus hexon-positive specimens were enteric serotypes, and by extrapolation, enteric adenoviruses were identified in an equal percentage of children (2%) with and without diarrhea. This study documents the presence of astrovirus and enteric adenoviruses among children in day care in the United States, associates astrovirus with diarrhea in this setting, and suggests that viral agents may be the most common enteric pathogens among children with diarrhea in day care.

Astroviruses as a cause of gastroenteritis in children

BACKGROUND

Infection with astroviruses has been associated with gastroenteritis in children, and serologic surveys indicate that this infection may be frequent. The importance of astroviruses as agents of gastroenteritis has not been shown in a controlled study, however.

METHODS

We used monoclonal antibody-based enzyme immunoassays to detect astroviruses, enteric adenoviruses, and rotaviruses in stool samples obtained from age-matched children with and children without gastroenteritis. The samples were obtained in two studies, three years apart, among patients attending an outpatient clinic in Bangkok, Thailand.

RESULTS

In the first study, astroviruses were detected in 8.6 percent (96 of 1111) of the children with gastroenteritis and in 2.0 percent (19 of 947) of the children without gastroenteritis. In the second study the rates were 8.6 percent (50 of 580) and 2.1 percent (11 of 512), respectively. For both studies combined, enteric adenoviruses were detected in 2.6 percent of those with gastroenteritis and in 0.5 percent of the controls, whereas rotaviruses were detected in 19 percent of those with gastroenteritis and in 1.0 percent of the controls. The clinical findings associated with astrovirus infection were similar to those associated with rotavirus infection, except for a trend toward greater dehydration in the children infected with rotaviruses.

CONCLUSIONS

These two controlled studies involving a total of 3150 Thai children provide evidence that astroviruses are a common cause of viral gastroenteritis. Astroviruses were found in association with gastroenteritis more frequently than were enteric adenoviruses, and with nearly half the frequency of rotaviruses.

Immunological characterization of the Marin County strain of astrovirus

Marin County virus (MCV) was isolated from a stool suspension and serially propagated in human embryonic kidney cell cultures. MCV particles in stool and cell-propagated virus stocks showed reactivity by immune electron microscopy (IEM) with rabbit antiserum to astrovirus type 5. MCV antigen was also detected in two MCV stool samples by enzyme immunoassay (EIA) with an astrovirus group-specific monoclonal antibody. Acute and convalescent sera from 3 of 3 MCV-infected patients showed seroconversion to cell-propagated MCV by EIA. Immunofluorescence of MCV propagated in cell culture showed positive reactivity with an astrovirus group specific monoclonal antibody and astrovirus type 5 antiserum, with some cross-reactivity with astrovirus type 1. Similar results were obtained with the prototype strain of astrovirus type 5. However, in plaque-reduction assays, both the prototype astrovirus type 5 and MCV were neutralized by type 5 antiserum only. We conclude that MCV can be serially propagated by techniques used for previously described astroviruses and is serotypically an astrovirus type 5.

Accuracy of Chlamydia trachomatis antigen detection methods in a low-prevalence population in a primary care setting

We compared a direct fluorescent-antibody stain (DFA) and an enzyme immunoassay (EIA) with a standard cell culture technique for the detection of Chlamydia trachomatis infection in women in an urban family practice setting. We also evaluated a DFA sample in a commercial laboratory to determine the interlaboratory reliability of this test. There were 268 women in the study; the EIA provided a higher sensitivity (83 versus 50%) and a higher positive predictive value (83 versus 69%) than the DFA test and comparably high specificity (99 versus 98%). Concordance between the two laboratories on the DFA test was not high when data were adjusted for chance agreement (kappa coefficient = 0.64). DFA validity was optimal with an elementary body cutoff of greater than 5, while EIA validity was optimal at the recommended cutoff of 0.1 optical density unit. None of 11 women with negative cultures after treatment had false-positive antigen tests. False-negative results with both tests were associated with low culture inclusion counts but were not strongly associated with the presence or absence of symptoms, menses, pregnancy, or recent antibiotic use. False-positive results with EIA were seen only for three women who had a chief complaint of vaginal discharge. Although the positive predictive value of DFA could be increased in high-prevalence subpopulations, EIA was still more valid in two such groups: teenagers and prenatal patients. These results indicate that EIA might be preferable for low- or moderate-prevalence populations in primary care settings and that a falloff in DFA sensitivity could be explained by lower infection burdens in low-prevalence groups.

Effect of rimantadine on cytotoxic T lymphocyte responses and immunity to reinfection in mice infected with influenza A virus

Administration of rimantadine to mice via drinking water, following a prophylactic dose, reduced lung virus titers by greater than 3 log10 plague-forming units (pfu)/ml but caused only marginal reductions in lung virus titers when therapy was started 8 h after exposure to virus. Mice given rimantadine prophylactically plus therapeutically were resistant to rechallenge with virus at a dose equivalent to that used for the primary infection (50 pfu/mouse) but not to a high dose (1 x 10(5) pfu/mouse). Virus-neutralizing-antibody titers were reduced only by rimantadine treatment, which included prophylaxis, whereas the cytotoxic T lymphocyte (CTL) response was depressed by treatment given with or without prophylaxis. Mice infected with rimantadine-resistant virus had no decrease in CTL or antibody responses when treated with rimantadine. Therefore, the depression in CTL and antibody responses associated with rimantadine treatment appears to be due to a decrease in the amount of viral antigen available or interference with viral antigen processing and not to nonspecific immunosuppressive effects.

Diagnosis of astrovirus gastroenteritis by antigen detection with monoclonal antibodies

An enzyme-linked immunosorbent assay (ELISA), based on monoclonal antibodies to the astrovirus group antigen, was designed for the detection of astroviruses in stools of patients with gastroenteritis. Compared to immune electron microscopy used as the standard test, the sensitivity of the astrovirus ELISA was 91% (31/34) and the specificity was 96% (54/56). All five of the known astrovirus serotypes could be detected in 16 samples on which serotyping was done. In tests on 155 stools containing other enteric viruses, including adenoviruses, rotaviruses, caliciviruses, Hawaii virus, Snow Mountain virus, and Norwalk virus (30, 20, 70, 24, 4, and 7 samples, respectively), only 3 were positive in the astrovirus ELISA. The combined specificity for all astrovirus immune electron microscopy-negative samples was 98% (206/211). The results demonstrate that the new ELISA provides a sensitive and specific means for the diagnosis of astrovirus gastroenteritis.

Efficacy of rimantadine hydrochloride in the treatment of influenza infection of mice

Rimantadine HCl was assessed for its effect on influenza A virus titer in lungs of infected BALB/c mice. Rimantadine administered orally via drinking water, with and without an intraperitoneal prophylactic loading dose, was compared to intraperitoneal administration. Mice were infected with a non-lethal dose of influenza A/Port Chalmers/H3N2 virus and the pulmonary virus titers were determined at intervals over a 21 day period. Prophylactic treatment with rimantadine followed by oral administration resulted in up to a 4 log10 reduction in pulmonary virus titer. The oral doses given to the mice were comparable on a mg/kg/day basis to those recommended for treatment of human infections. Reductions in pulmonary virus titers also occurred after intraperitoneal rimantadine treatment which included a prophylactic dose, but the reductions in pulmonary virus titers were less striking and not consistent over the course of infection. There were no significant reductions in pulmonary virus titers by either route if treatment was started 8 h after exposure to virus.

Plaque quantitation and virus neutralization assays for human astroviruses

Astroviruses, 28 nm-diameter, RNA-containing viruses which have been implicated in gastroenteritis can be cultivated in cell cultures containing trypsin, but do not show distinguishable cytopathic effects. However, with the 5 known astrovirus serotypes which we have been able to cultivate, 3 (types 1, 2, and 5) formed well-defined plaques in LLCMK2 cell cultures under an agar overlay containing trypsin. A virus neutralization assay based on plaque reduction was applied to these 3 serotypes. It was found that rabbit antisera prepared against individual serotypes neutralized virus type-specifically, and no cross-neutralization titers were obtained with any of the antisera to the 5 astrovirus serotypes. The type-specific neutralization observed agreed with the specificities seen by immunofluorescence (IF), whereas ELISA tests with the same antisera show cross-reactivity among all 5 serotypes. There was no virus neutralization detected with astrovirus monoclonal antibodies which were reactive with 5 serotypes by ELISA and IF. The results we have obtained permit quantitative techniques to be applied to epidemiological and biological studies of the human astroviruses.

Role of Norwalk virus in two foodborne outbreaks of gastroenteritis: definitive virus association

Two separate food-associated outbreaks of gastroenteritis occurred among Erie County, New York residents in June 1986. In one outbreak, cases of illness were estimated to have occurred in 50% of the approximately 700 persons in 13 groups who ate at an out-of-county restaurant during a seven-day period, and, in the second outbreak, illness occurred in 26 (30%) of 87 persons who attended a graduation party held in a private home. Laboratory investigation included serology (blocking radioimmunoassay) to determine seroconversion to Norwalk virus and an enzyme immunoassay for detection of Norwalk virus antigen in stools, which the investigators have found to be more specific for Norwalk virus than serology. Seroconversion to Norwalk virus occurred in 11 (79%) of 14 restaurant-related cases and seven (100%) of seven graduation party cases. Seroconversion to Norwalk virus antigen was also found in four (40%) of 10 food handlers at the restaurant and in two (100%) of two food handlers at the graduation party. Antigen was detected in the stools of three (20%) of 15 restaurant-related cases and four (67%) of six graduation party cases. No stools for viral analyses were available for testing from food handlers. All seven of the patients with Norwalk virus-positive stools were also positive by seroconversion. Widespread availability of reagents for stool antigen detection would result in confirmation of more outbreaks due to Norwalk virus and in a more timely manner.

Incidence of enteric adenoviruses among children in Thailand and the significance of these viruses in gastroenteritis

In countries with temperate climates, enteric adenoviruses have been shown to be a substantial cause of pediatric gastroenteritis. To determine the incidence of adenovirus infection in a tropical climate, stools were collected from children under age 7 during a 1-year period at an outpatient clinic in Bangkok, Thailand. Stools from 1,114 children with gastroenteritis and from 947 children without gastroenteritis were tested. Each stool was tested for adenovirus group antigen and for specific enteric adenovirus types (Ad40 and Ad41) by monoclonal antibody enzyme immunoassays. We found that 4.4% (49 of 1,114) of children with gastroenteritis and 1.8% (17 of 947) of children without gastroenteritis were positive for adenovirus group antigen. In tests for specific enteric adenovirus types, 2.0% (22 of 1,114) of the tests were positive in children with gastroenteritis and 0.6% (6 of 947) were positive in children without gastroenteritis. There was a significant correlation (P less than 0.02) of gastroenteritis with nonenteric adenovirus types (27 of 1,114) as well as with specific enteric adenovirus types (P less than 0.01). By comparison, 19.7% of children with gastroenteritis and 0.7% of those without gastroenteritis were positive for rotavirus infection. In the adenovirus-infected children with gastroenteritis, there were coinfections with rotavirus only in those with nonenteric adenovirus infection (7 of 27 children). There were no significant differences in the association of bacterial or parasitic infections with either enteric or nonenteric adenovirus infections in either group of children studied. These data demonstrate that Ad40 and Ad41 are causes of gastroenteritis in this population, but among the spectrum of diarrheal etiologies, they may be proportionately less important than they are in countries with temperate climates.

Isolation and propagation of enteric adenoviruses in HEp-2 cells

Eighty-two stool samples from children with gastroenteritis in Canada, England, and Thailand which had been shown to contain adenovirus antigen (by a group-specific enzyme-linked immunosorbent assay) or adenovirus particles (by electron microscopy) or both, were tested for primary isolation of enteric adenoviruses in HEp-2 and Graham 293 cells. Graham 293 cells are known to support the replication of enteric adenovirus types (Ad40 and Ad41) on primary isolation, whereas HEp-2 cells reportedly do not. Of the 82 adenovirus isolates, 73 could be typed as Ad40 or Ad41 by type-specific monoclonal antibody enzyme-linked immunosorbent assay and by analysis of SmaI endonuclease digests. Of these 73, 30 (41%) could be isolated in HEp-2 cells, which included 43% (9/21) of those typed as Ad40 and 40% (21/52) of those typed as Ad41. On the basis of these results, the growth characteristics of adenoviruses in HEp-2 cell cultures, commonly used to distinguish enteric from nonenteric adenovirus types, are not valid for either diagnosis or epidemiological studies. For the samples studied here, use of these nondefinitive criteria would result in underestimation of the incidence of enteric adenoviruses in viral gastroenteritis.

Antigenic characterization of cell-cultivated astrovirus serotypes and development of astrovirus-specific monoclonal antibodies

Cultivation of human astroviruses in human embryonic kidney or LLCMK2 cell cultures was corroborated for four of the five serotypes originally reported (types 1, 2, 4, and 5). By using type-specific rabbit antisera and immunofluorescence of virus-infected cells, we readily distinguished between serotypes of astrovirus; however, these serotypes showed a high degree of cross-reactivity by enzyme-linked immunoassay, a result indicating the presence of a group antigen. We prepared monoclonal antibodies to astrovirus type 2 antigen and selected them on the basis of group antigen reactivity. The antibodies were reactive with the four astrovirus serotypes that we could cultivate, as well as with the Marin County strain of astrovirus. A previously reported cell-cultivated astrovirus type 3 also reacted with the monoclonal antibodies. These monoclonal antibodies, and the finding of group reactivity among the human astroviruses, should facilitate studies on the importance of these viruses as agents of viral gastroenteritis.

Application of DNA hybridization techniques in the assessment of diarrheal disease among refugees in Thailand

The epidemiology and etiology of acute diarrheal disease were determined in a Hmong refugee camp on the Thai-Laotian border from April 11 to May 14, 1985. DNA hybridization techniques were used to detect Shigella species, enteroinvasive Escherichia coli, and enterotoxigenic E. coli. A monoclonal enzyme-linked immunosorbent assay was used to detect rotavirus, and standard microbiology was used to detect other enteropathogens. The age-specific diarrheal disease rates were 47 episodes per month per 1,000 children less than five years old and 113 episodes per month per 1,000 children less than one year old. Rotavirus, enterotoxigenic E. coli, Campylobacter, and Cryptosporidium were the predominant pathogens in children less than two years old. The DNA probe hybridized with 94% of 31 specimens identified as enterotoxigenic E. coli by the standard assays and with none of the specimens in which the standard assays were negative. The probe for Shigella and enteroinvasive E. coli hybridized in eight of 10 stools that contained Shigella and four of 314 stools from which Shigella and enteroinvasive E. coli were not isolated. The use of DNA probes allows specimens to be collected in remote areas with a minimum amount of equipment and technical expertise so that they can be easily transported to a central laboratory for further processing.

Antigenic relationships between human caliciviruses and Norwalk virus

We investigated antigenic relationships between human calicivirus (HCV) strains and Norwalk virus by using immune electron microscopy (IEM) and radioimmunoassay (RIA). Three serologically distinct HCV strains, UK1, UK2, and Japan, were demonstrated by IEM, as was evidence for two additional strains, UK3 and UK4. Although HCV strains and Norwalk virus were distinct by IEM, 12 of 20 patients with gastroenteritis due to HCV UK4 and two of eight with gastroenteritis due to UK2 showed seroconversions to Norwalk virus by RIA. These naturally occurring antibody responses in humans, as detected by RIA, support the concept that Norwalk virus belongs to the family Caliciviridae. An RIA for HCV Japan antigen also detected HCV UK1, UK2, and UK4 and thus appears to identify a group-specific antigen for these viruses. An RIA for antibody to HCV Japan failed to identify seroconversions in 45 of 47 patients with gastroenteritis due to HCV UK. These results may reflect different reactivities of various immunologic tests for the identification of infections due to small gastroenteritis viruses.

Preparation and characterization of monoclonal antibodies to enteric adenovirus types 40 and 41

We have prepared monoclonal antibodies to each of the enteric adenoviruses types 40 and 41. Three different hybridoma cell lines were selected which produced antibody found to react by radioimmunoprecipitation with adenovirus (Ad) hexon antigens. One was specific for Ad 40, another for Ad 41, and a third one reacted with both types. When tested in an enzyme immunoassay against all 41 known human Ad types, the type-specific monoclonal antibody against Ad 40 reacted homotypically, as did the monoclonal antibody against Ad 41. In addition, these monoclonal antibodies neutralized the homologous enteric Ad type. The monoclonal antibody which reacted with both enteric Ad types also showed lower levels of reactivity with the group C adenoviruses types 2, 5, and 6. The monoclonal antibodies produced will provide a definitive means for rapid identification of specific Ad types, and will be useful in defining the relationship of enteric adenoviruses to other types.

Antigen detection with monoclonal antibodies for the diagnosis of adenovirus gastroenteritis

A monoclonal antibody-based enzyme immunoassay (EIA) was developed for direct detection of enteric adenoviruses in stool specimens from individuals with gastroenteritis. Tests specific for each of the enteric adenoviruses, adenovirus type 40 (Ad 40) and type 41 (Ad 41), were designed. The sensitivity of the assay was determined by comparing the results of the EIA with isolation of virus in Graham 293 cells from stools that contained particles having adenovirus morphology. The standard for specificity was analysis of adenovirus genome profiles after digestion with SmaI endonuclease. The sensitivity was 95.8% (23 of 24) for Ad 40 and 97.1% (34 of 35) for Ad 41. The specificity was 95.7% (45 of 47) and 97.2% (35 of 36), respectively. The two type-specific monoclonal antibodies could be mixed in an EIA for identification of enteric adenoviruses in stools without loss of reactivity in either type. The EIA permits rapid diagnosis and type-specific identification of enteric adenoviruses in gastroenteritis.

Foodborne Snow Mountain agent gastroenteritis in a school cafeteria

In 1984, an outbreak of gastroenteritis occurred at a school with 1,860 students in Brooklyn, NY. In a single-stage cluster sample of 375 students, 129 (34%) had illnesses that met our case definition of vomiting or diarrhea. The mean incubation period was 26 hours, and the mean illness duration was 24 hours. All case students had eaten in the cafeteria on at least one day between Nov 13 and 16, compared with 174/214 (81%) noncase students (P = 10(-8), Fisher exact test). Foods implicated were french fries (relative risk 1.7, 95% confidence limits 1.4, 2.0) and hamburgers (relative risk 1.6, 95%, confidence limits 1.2, 2.1). Two cafeteria employees had served those foods while affected by diarrhea. By a recently developed blocking enzyme-linked immunosorbent assay, six of 11 (55%) case students showed fourfold antibody increases between acute- and convalescent-phase serum samples for Snow Mountain agent, a Norwalk-like virus, compared with one of ten (10%) noncase students (P = .04, Fisher exact test). We strongly suspect, but cannot document conclusively, that the Snow Mountain agent was spread to students on a vector of hot foods contaminated by ill food handlers. Implicated foods conferred low relative risks and could only have accounted for 74% of cases of illness. The strong association between cafeteria exposure and illness, therefore, suggests that additional modes of spread occurred.