Management of fever and neutropenia in paediatric cancer patients: room for improvement?

PURPOSE OF REVIEW Fever and neutropenia is the most common complication in the treatment of childhood cancer. This review will summarize recent publications that focus on improving the management of this condition as well as those that seek to optimize translational research efforts. RECENT FINDINGS A number of clinical decision rules are available to assist in the identification of low-risk fever and neutropenia however few have undergone external validation and formal impact analysis. Emerging evidence suggests acute fever and neutropenia management strategies should include time to antibiotic recommendations, and quality improvement initiatives have focused on eliminating barriers to early antibiotic administration. Despite reported increases in antimicrobial resistance, few studies have focused on the prediction, prevention, and optimal treatment of these infections and the effect on risk stratification remains unknown. A consensus guideline for paediatric fever and neutropenia research is now available and may help reduce some of the heterogeneity between studies that have previously limited the translation of evidence into clinical practice. SUMMARY Risk stratification is recommended for children with cancer and fever and neutropenia. Further research is required to quantify the overall impact of this approach and to refine exactly which children will benefit from early antibiotic administration as well as modifications to empiric regimens to cover antibiotic-resistant organisms.

Report from the National Institute of Allergy and Infectious Diseases workshop on drug allergy

Allergic reactions to drugs are a serious public health concern. In 2013, the Division of Allergy, Immunology, and Transplantation of the National Institute of Allergy and Infectious Diseases sponsored a workshop on drug allergy. International experts in the field of drug allergy with backgrounds in allergy, immunology, infectious diseases, dermatology, clinical pharmacology, and pharmacogenomics discussed the current state of drug allergy research. These experts were joined by representatives from several National Institutes of Health institutes and the US Food and Drug Administration. The participants identified important advances that make new research directions feasible and made suggestions for research priorities and for development of infrastructure to advance our knowledge of the mechanisms, diagnosis, management, and prevention of drug allergy. The workshop summary and recommendations are presented herein.

Health education intervention to reduce risk of infectious disease transmission among community health workers and their clients

Indigent and congregate-living populations have high susceptibilities for disease and pose a higher risk for disease transmission to family, friends and to persons providing services to these populations. The adoption of basic infection control, personal hygiene, safe food handling and simple engineering practices will reduce the risk of infectious disease transmission to, from and among indigent and congregate-living populations. ^ The provision of social services, health promotion activities and other support services to indigent and congregate-living populations is an important aspect of many public health-related governmental, community-based and other medical care provider agencies. ^ In the interest of protecting the health of indigent and congregate-living populations, of personnel from organizations providing services to these populations and of the general community, an educational intervention is warranted to prevent the spread of blood-borne, air-borne, food-borne and close contact-borne infectious diseases. ^ An educational presentation was provided to staff from a community-based organization specializing in providing housing, health education, foodstuffs and meals and support services to disabled, low-income, homeless and HIV-infected individuals. The educational presentation delivered general best practices and standard guidelines. A pre and post test were administered to determine and measure knowledge pertinent to controlling the spread of infectious diseases between and among homeless shelter-living clients and between clients and the organization's staff. ^ Comparing pre-test and post-test results revealed areas of knowledge currently held by staff and other areas that staff would benefit from additional educational seminars and training. ^

The association of previous induced abortion with the subsequent pregnancy complication of placenta previa

Placenta previa is alleged to be more common among women with a history of prior induced abortion. To investigate further whether there is a relationship between previous induced abortion and subsequent pregnancy complication of placenta previa, a matched case-comparison study was conducted comparing the reproductive histories of 256 women with placenta previa matched on age, date of delivery, and hospital with those of 256 women having normal deliveries and cesarean section deliveries without placental complications.^ Women with placenta previa had a twofold increase in the odds of having had one previous induced abortion (odds ratio 2.25) over women with no placental complications. Women with placenta previa and two or more previous induced abortions had a sevenfold increase in odds.^ The significant association of placenta previa and previous induced abortion remained after including gravida status, previous dilatation and curettage (D&C) status, previous spontaneous abortion, and race in a conditional logistic regression model. There is interaction between high gravidity and previous spontaneous abortion. Dilatation and curettage is associated with placenta previa primarily because women with abortion histories have also had a dilatation and curettage.^ Women who are seeking abortion and wish to have children later should be informed that there may be a longterm effect of developing placental complications in subsequent pregnancies. Women who have had at least one induced abortion or any dilatation and curettage procedure should be monitored carefully during any subsequent pregnancy for the risk of the complication of placenta previa. This knowledge should alert the physician or nurse-midwife to treat those women with a history of previous induced abortions as potential high risk pregnancies and could perhaps reduce maternal and fetal morbidity rates. ^

Infectious diseases, immune status, and health insurance among child care providers in Houston, Texas

The objectives of this study were to compare female child-care providers with female university workers and with mothers of children in child-care centers for: (1) frequency of illness and work loss days due to infectious diseases, (2) prevalence of antibodies against measles, rubella, mumps, hepatitis B, hepatitis A, chickenpox and cytomegalovirus (CMV), and (3) status regarding health insurance and job benefits.^ Subjects from twenty child-care centers and twenty randomly selected departments of a university in Houston, Texas were studied in a cross-sectional fashion.^ A cluster sample of 281 female child-care providers from randomly selected child-care centers, a cluster sample of 286 university workers from randomly selected departments and a systematic sample of 198 mothers of children from randomly selected child-care centers.^ Main outcome measures were: (1) self-reported frequency of infectious diseases and number of work-days lost due to infectious diseases; (2) presence of antibodies in blood; and (3) self-reported health insurance and job benefits.^ In comparison to university workers, child-care providers reported a higher prevalence of infectious diseases in the past 30 days; lost three times more work-days due to infectious diseases; and were more likely to have anti-core antibodies against hepatitis B (odds ratio = 3.16 95% CI 1.27-7.85) and rubella (OR 1.88, 95% CI 1.02-3.45). Child-care providers had less health insurance and job-related benefits than mothers of children attending child-care centers.^ Regulations designed to reduce transmission of vaccine and non-vaccine preventable diseases in child-care centers should be strictly enforced. In addition policies to improve health insurance and job benefits of child-care providers are urgently needed. ^

THE BACON CHOW STUDY: THE RELATIONSHIP BETWEEN INFECTIOUS ILLNESS AND GROWTH OF INFANTS

Multiple dietary deficiencies and high rates of infectious illness are major health problems leading to malnutrition and limitation of growth of children in developing countries. Longitudinal studies which provide information on illness incidence and growth velocity are needed in order to untangle the complex interrelationship between nutrition, illness and growth. From 1967 to 1973, researchers led by Dr. Bacon Chow of the Johns Hopkins University School of Hygiene undertook a quasi-experimental prospective study in Suilin Township, Taiwan to determine the effects of a nutritional supplement to the diets of pregnant and lactating women on the growth, development and resistance to disease of their offspring. This dissertation presents results from the analysis of infant morbidity and postnatal growth.^ Maternal nutritional supplementation has no apparent effect on the postnatal growth or morbidity of infants. Significant sex differences exist in growth response to illness and in illness susceptibility. Male infants have more diarrhea and upper respiratory illness. Respiratory illness is positively associated with growth rate in weight in the first semester of life. Diarrhea is significantly negatively associated with growth in length in the second semester. Small-for-date infants are more susceptible to illness in general and have a different pattern of growth response than large-for-date infants.^ Principal components analysis of illness data is shown to be an effective technique for making more precise use of ambiguous morbidity data. Multiple regression with component scores is an accurate method for estimating variance in growth rate predicted by indepenent illness variables. A model is advanced in which initial postnatal growth rate determines subsequent susceptibility to nutritional stress and infection. Initial growth rate is a function of prenatal nutrition, but is not significantly affected by maternal supplementation during gestation or lactation. Critical evaluation is made of nutritional supplementation programs which do not afford disease control.^

A health disparities perspective on developing emerging infectious disease preparedness

A systematic review of the literature yielded 10 articles that explored the interaction between race/ethnicity, citizenship, socioeconomic status, and health literacy domains with respect to preparedness agenda development. Current emerging infectious disease (EID) preparedness plans do not adequately address the needs of vulnerable populations for the events before, during, and after an epidemic. Central to the disadvantage of most vulnerable populations are various health disparity domains that persist as barriers for individuals and communities alike to engage in preparedness efforts. Seven out of the ten articles discussed the importance of including health disparity domains in preparedness policy. Two proposed frameworks for an emerging infectious disease framework that considers health disparities are presented in this study. ^ Framework 1 is beneficial for the evaluation phase after a disaster has struck and preparedness efforts have been initiated. It considers several existing disparities and remediation strategies at the individual, community, and system levels to reach adequate restructuring of preparedness aims. Framework 2 serves as a "how to" carry out preparedness during a disaster event. It is a revision of a framework proposed by Blumenshine et al. (2008) and explores those characteristics central to pandemic preparedness plan development/deployment. Although two frameworks were devised, no one framework will adequately address the needs of vulnerable populations during an epidemic. However, the two frameworks propose to demonstrate the inclusion of important health disparity domains in preparedness plan development. ^ The National Consensus Panel for Emergency Preparedness and Cultural Diversity has released guidelines that are considered the leading strategies necessary to reorient preparedness infrastructure. In order for vulnerable populations to benefit from ample protection during a disaster, inclusion of health disparity domains in the development phases of preparedness must occur prior to full deployment in communities. Although "promising practices" and other methods at the frontier of exploring these multidimensional constraints has entered the research arena, new studies on adequate preparedness merit further investigation and support.^

Transcripts from a single full-length cDNA clone of hepatitis C virus are infectious when directly transfected into the liver of a chimpanzee

We have succeeded in constructing a stable full-length cDNA clone of strain H77 (genotype 1a) of hepatitis C virus (HCV). We devised a cassette vector with fixed 5′ and 3′ termini and constructed multiple full-length cDNA clones of H77 in a single step by cloning of the entire ORF, which was amplified by long reverse transcriptase–PCR, directly into this vector. The infectivity of two complete full-length cDNA clones was tested by the direct intrahepatic injection of a chimpanzee with RNA transcripts. However, we found no evidence for HCV replication. Sequence analysis of these and 16 additional full-length clones revealed that seven clones were defective for polyprotein synthesis, and the remaining nine clones had 6–28 amino acid mutations in the predicted polyprotein compared with the consensus sequence of H77. Next, we constructed a consensus chimera from four of the full-length cDNA clones with just two ligation steps. Injection of RNA transcripts from this consensus clone into the liver of a chimpanzee resulted in viral replication. The sequence of the virus recovered from the chimpanzee was identical to that of the injected RNA transcripts. This stable infectious molecular clone should be an important tool for developing a better understanding of the molecular biology and pathogenesis of HCV.

Solution structure of a 142-residue recombinant prion protein corresponding to the infectious fragment of the scrapie isoform

The scrapie prion protein (PrPSc) is the major, and possibly the only, component of the infectious prion; it is generated from the cellular isoform (PrPC) by a conformational change. N-terminal truncation of PrPSc by limited proteolysis produces a protein of ≈142 residues designated PrP 27–30, which retains infectivity. A recombinant protein (rPrP) corresponding to Syrian hamster PrP 27–30 was expressed in Escherichia coli and purified. After refolding rPrP into an α-helical form resembling PrPC, the structure was solved by multidimensional heteronuclear NMR, revealing many structural features of rPrP that were not found in two shorter PrP fragments studied previously. Extensive side-chain interactions for residues 113–125 characterize a hydrophobic cluster, which packs against an irregular β-sheet, whereas residues 90–112 exhibit little defined structure. Although identifiable secondary structure is largely lacking in the N terminus of rPrP, paradoxically this N terminus increases the amount of secondary structure in the remainder of rPrP. The surface of a long helix (residues 200–227) and a structured loop (residues 165–171) form a discontinuous epitope for binding of a protein that facilitates PrPSc formation. Polymorphic residues within this epitope seem to modulate susceptibility of sheep and humans to prion disease. Conformational heterogeneity of rPrP at the N terminus may be key to the transformation of PrPC into PrPSc, whereas the discontinuous epitope near the C terminus controls this transition.

Noninfectious virus-like particles produced by Moloney murine leukemia virus-based retrovirus packaging cells deficient in viral envelope become infectious in the presence of lipofection reagents

Retrovirus packaging cell lines expressing the Moloney murine leukemia virus gag and pol genes but lacking virus envelope genes produce virus-like particles constitutively, whether or not they express a transcript from an integrated retroviral provirus. In the absence of a proviral transcript, the assembled particles contain processed gag and reverse transcriptase, and particles made by cells expressing an integrated lacZ provirus also contain viral RNA. The virus-like particles from both cell types are enveloped and are secreted/budded into the extracellular space but are noninfectious. Their physicochemical properties are similar to those of mature retroviral particles. The noninfectious gag pol RNA particles can readily be made infectious by the addition of lipofection reagents to produce preparations with titers of up to 105 colony-forming units per ml.

Cloning and mutagenesis of a herpesvirus genome as an infectious bacterial artificial chromosome

A strategy for cloning and mutagenesis of an infectious herpesvirus genome is described. The mouse cytomegalovirus genome was cloned and maintained as a 230 kb bacterial artificial chromosome (BAC) in E. coli. Transfection of the BAC plasmid into eukaryotic cells led to a productive virus infection. The feasibility to introduce targeted mutations into the BAC cloned virus genome was shown by mutation of the immediate-early 1 gene and generation of a mutant virus. Thus, the complete construction of a mutant herpesvirus genome can now be carried out in a controlled manner prior to the reconstitution of infectious progeny. The described approach should be generally applicable to the mutagenesis of genomes of other large DNA viruses.

Density-dependent decline of host abundance resulting from a new infectious disease

Although many new diseases have emerged within the past 2 decades [Cohen, M. L. (1998) Brit. Med. Bull. 54, 523–532], attributing low numbers of animal hosts to the existence of even a new pathogen is problematic. This is because very rarely does one have data on host abundance before and after the epizootic as well as detailed descriptions of pathogen prevalence [Dobson, A. P. & Hudson, P. J. (1985) in Ecology of Infectious Diseases in Natural Populations, eds. Grenfell, B. T. & Dobson, A. P. (Cambridge Univ. Press, Cambridge, U.K.), pp. 52–89]. Month by month we tracked the spread of the epizootic of an apparently novel strain of a widespread poultry pathogen, Mycoplasma gallisepticum, through a previously unknown host, the house finch, whose abundance has been monitored over past decades. Here we are able to demonstrate a causal relationship between high disease prevalence and declining house finch abundance throughout the eastern half of North America because the epizootic reached different parts of the house finch range at different times. Three years after the epizootic arrived, house finch abundance stabilized at similar levels, although house finch abundance had been high and stable in some areas but low and rapidly increasing in others. This result, not previously documented in wild populations, is as expected from theory if transmission of the disease was density dependent.

Engineering the largest RNA virus genome as an infectious bacterial artificial chromosome

The construction of cDNA clones encoding large-size RNA molecules of biological interest, like coronavirus genomes, which are among the largest mature RNA molecules known to biology, has been hampered by the instability of those cDNAs in bacteria. Herein, we show that the application of two strategies, cloning of the cDNAs into a bacterial artificial chromosome and nuclear expression of RNAs that are typically produced within the cytoplasm, is useful for the engineering of large RNA molecules. A cDNA encoding an infectious coronavirus RNA genome has been cloned as a bacterial artificial chromosome. The rescued coronavirus conserved all of the genetic markers introduced throughout the sequence and showed a standard mRNA pattern and the antigenic characteristics expected for the synthetic virus. The cDNA was transcribed within the nucleus, and the RNA translocated to the cytoplasm. Interestingly, the recovered virus had essentially the same sequence as the original one, and no splicing was observed. The cDNA was derived from an attenuated isolate that replicates exclusively in the respiratory tract of swine. During the engineering of the infectious cDNA, the spike gene of the virus was replaced by the spike gene of an enteric isolate. The synthetic virus replicated abundantly in the enteric tract and was fully virulent, demonstrating that the tropism and virulence of the recovered coronavirus can be modified. This demonstration opens up the possibility of employing this infectious cDNA as a vector for vaccine development in human, porcine, canine, and feline species susceptible to group 1 coronaviruses.

Production of infectious bovine papillomavirus from cloned viral DNA by using an organotypic raft/xenograft technique

Bovine papillomavirus type 1 (BPV-1) induces fibropapillomas in its natural host and can transform fibroblasts in culture. The viral genome is maintained as an episome within fibroblasts, which has allowed extensive genetic analyses of the viral functions required for DNA replication, gene expression, and transformation. Much less is known about BPV-1 gene expression and replication in bovine epithelial cells because the study of the complete viral life cycle requires an experimental system capable of generating a fully differentiated stratified bovine epithelium. Using a combination of organotypic raft cultures and xenografts on nude mice, we have developed a system in which BPV-1 can replicate and produce infectious viral particles. Organotypic cultures were established with bovine keratinocytes plated on a collagen raft containing BPV-1-transformed fibroblasts. These keratinocytes were infected with virus particles isolated from a bovine wart or were transfected with cloned BPV-1 DNA. Several days after the rafts were lifted to the air interface, they were grafted on nude mice. After 6–8 weeks, large xenografts were produced that exhibited a hyperplastic and hyperkeratotic epithelium overlying a large dermal fibroma. These lesions were strikingly similar to a fibropapilloma caused by BPV-1 in the natural host. Amplified viral DNA and capsid antigens were detected in the suprabasal cells of the epithelium. Moreover, infectious virus particles could be isolated from these lesions and quantitated by a focus formation assay on mouse cells in culture. Interestingly, analysis of grafts produced with infected and uninfected fibroblasts indicated that the fibroma component was not required for productive infection or morphological changes characteristic of papillomavirus-infected epithelium. This system will be a powerful tool for the genetic analysis of the roles of the viral gene products in the complete viral life cycle.

Climate and infectious disease: Use of remote sensing for detection of Vibrio cholerae by indirect measurement

It has long been known that cholera outbreaks can be initiated when Vibrio cholerae, the bacterium that causes cholera, is present in drinking water in sufficient numbers to constitute an infective dose, if ingested by humans. Outbreaks associated with drinking or bathing in unpurified river or brackish water may directly or indirectly depend on such conditions as water temperature, nutrient concentration, and plankton production that may be favorable for growth and reproduction of the bacterium. Although these environmental parameters have routinely been measured by using water samples collected aboard research ships, the available data sets are sparse and infrequent. Furthermore, shipboard data acquisition is both expensive and time-consuming. Interpolation to regional scales can also be problematic. Although the bacterium, V. cholerae, cannot be sensed directly, remotely sensed data can be used to infer its presence. In the study reported here, satellite data were used to monitor the timing and spread of cholera. Public domain remote sensing data for the Bay of Bengal were compared directly with cholera case data collected in Bangladesh from 1992–1995. The remote sensing data included sea surface temperature and sea surface height. It was discovered that sea surface temperature shows an annual cycle similar to the cholera case data. Sea surface height may be an indicator of incursion of plankton-laden water inland, e.g., tidal rivers, because it was also found to be correlated with cholera outbreaks. The extensive studies accomplished during the past 25 years, confirming the hypothesis that V. cholerae is autochthonous to the aquatic environment and is a commensal of zooplankton, i.e., copepods, when combined with the findings of the satellite data analyses, provide strong evidence that cholera epidemics are climate-linked.