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Tropical travelers’ top dermatologic infestations
WAIKOLOA, HAWAII – The Caribbean islands and Central and South America are among the most popular travel destinations for Americans. And some of these visitors will come home harboring unwelcome guests: Infestations that will eventually bring them to a dermatologist’s attention.
“I always tell the residents that if a patient’s country of travel starts with a B – Barbados, Belize, Bolivia, Brazil – it’s going to be something fun,” Natasha A. Mesinkovska, MD, PhD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
According to surveillance conducted by the Centers for Disease Control and Prevention and the International Society for Travel Medicine,
Cutaneous larva migrans is the easiest to diagnosis because it’s a creeping eruption that often migrates at a rate of 1-2 cm per day. Patients with the other disorders often present with a complaint of a common skin condition – described as a pimple, a wart, a patch of sunburn – that just doesn’t go away, according to Dr. Mesinkovska, director of clinical research in the department of dermatology at the University of California, Irvine.
Tungiasis
Tungiasis is caused by the female sand flea, Tunga penetrans, which burrows into the skin, where it lays hundreds of eggs within a matter of a few days. The sand flea is harbored by dogs, cats, pigs, cows, and rats. It’s rare to encounter tungiasis in travelers who’ve spent their time in fancy resorts, ecolodges, or yoga retreats, even if they’ve been parading around with lots of exposed skin. This is a disease of impoverished neighborhoods; hence, affected Americans often have been doing mission work abroad. In tropical areas, tungiasis is a debilitating, mutilating disorder marked by repeated infections, persistent inflammation, fissures, and ulcers.
Treatment involves a topical antiparasitic agent such as ivermectin, metrifonate, or thiabendazole and removal of the flea with sterile forceps or needles. But there is a promising new treatment concept: topical dimethicone, or polydimethylsiloxane. Studies have shown that following application of dimethicone, roughly 80%-90% of sand fleas are dead within 7 days.
“It’s nontoxic and has a purely physical mechanism of action, so resistance is unlikely ... I think it’s going to change the way this condition gets controlled,” Dr. Mesinkovska said.
Myiasis
The differential diagnosis of myiasis includes impetigo, a furuncle, an infected cyst, or a retained foreign body. Myiasis is a cutaneous infestation of the larva of certain flies, among the most notorious of which are the botfly, blowfly, and screwfly. The female fly lays her eggs in hot, humid, shady areas in soil contaminated by feces or urine. The larva can invade unbroken skin instantaneously and painlessly. Then it begins burrowing in. An air hole is always present in the skin so the organism can breathe. Ophthalmomyiasis is common, as are nasal and aural infections, the latter often accompanied by complaints of a crawling sensation inside the ear along with a buzzing noise. To avoid infection, in endemic areas it’s important not to go barefoot or to dry clothes on bushes or on the ground. Treatment entails elimination of the larva. Covering the air hole with petroleum jelly will force it to the surface. There is just one larva per furuncle, so no need for further extensive exploration once that critter has been extracted.
Leishmaniasis
The vector for this protozoan infection is the sandfly, which feeds from dusk to dawn noiselessly and painlessly. Because cutaneous and mucocutaneous leishmaniasis are understudied orphan diseases for which current treatments are less than satisfactory, prevention is the watchword. In endemic areas it’s important to close the windows and make use of air conditioning and ceiling fans when available. When in doubt, it’s advisable to sleep using a bed net treated with permethrin.
Cutaneous larva migrans
This skin eruption is caused by parasitic hookworms, the most common of which in the Americas is Ancylostoma braziliense. The eggs are transmitted through dog and cat feces deposited on soil or sand.
“Avoid laying or sitting on dry sand, even on a towel. And wear shoes,” Dr. Mesinkovska advised.
Among the CDC’s treatment recommendations for cutaneous larva migrans are several agents with poor efficacy and/or considerable side effects. But there is one standout therapy.
“Really, I would say nowadays the easiest thing is one 12-mg oral dose of ivermectin. It’s almost 100% effective,” she said.
Dr. Mesinkovska reported having no financial interests relevant to her talk.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
WAIKOLOA, HAWAII – The Caribbean islands and Central and South America are among the most popular travel destinations for Americans. And some of these visitors will come home harboring unwelcome guests: Infestations that will eventually bring them to a dermatologist’s attention.
“I always tell the residents that if a patient’s country of travel starts with a B – Barbados, Belize, Bolivia, Brazil – it’s going to be something fun,” Natasha A. Mesinkovska, MD, PhD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
According to surveillance conducted by the Centers for Disease Control and Prevention and the International Society for Travel Medicine,
Cutaneous larva migrans is the easiest to diagnosis because it’s a creeping eruption that often migrates at a rate of 1-2 cm per day. Patients with the other disorders often present with a complaint of a common skin condition – described as a pimple, a wart, a patch of sunburn – that just doesn’t go away, according to Dr. Mesinkovska, director of clinical research in the department of dermatology at the University of California, Irvine.
Tungiasis
Tungiasis is caused by the female sand flea, Tunga penetrans, which burrows into the skin, where it lays hundreds of eggs within a matter of a few days. The sand flea is harbored by dogs, cats, pigs, cows, and rats. It’s rare to encounter tungiasis in travelers who’ve spent their time in fancy resorts, ecolodges, or yoga retreats, even if they’ve been parading around with lots of exposed skin. This is a disease of impoverished neighborhoods; hence, affected Americans often have been doing mission work abroad. In tropical areas, tungiasis is a debilitating, mutilating disorder marked by repeated infections, persistent inflammation, fissures, and ulcers.
Treatment involves a topical antiparasitic agent such as ivermectin, metrifonate, or thiabendazole and removal of the flea with sterile forceps or needles. But there is a promising new treatment concept: topical dimethicone, or polydimethylsiloxane. Studies have shown that following application of dimethicone, roughly 80%-90% of sand fleas are dead within 7 days.
“It’s nontoxic and has a purely physical mechanism of action, so resistance is unlikely ... I think it’s going to change the way this condition gets controlled,” Dr. Mesinkovska said.
Myiasis
The differential diagnosis of myiasis includes impetigo, a furuncle, an infected cyst, or a retained foreign body. Myiasis is a cutaneous infestation of the larva of certain flies, among the most notorious of which are the botfly, blowfly, and screwfly. The female fly lays her eggs in hot, humid, shady areas in soil contaminated by feces or urine. The larva can invade unbroken skin instantaneously and painlessly. Then it begins burrowing in. An air hole is always present in the skin so the organism can breathe. Ophthalmomyiasis is common, as are nasal and aural infections, the latter often accompanied by complaints of a crawling sensation inside the ear along with a buzzing noise. To avoid infection, in endemic areas it’s important not to go barefoot or to dry clothes on bushes or on the ground. Treatment entails elimination of the larva. Covering the air hole with petroleum jelly will force it to the surface. There is just one larva per furuncle, so no need for further extensive exploration once that critter has been extracted.
Leishmaniasis
The vector for this protozoan infection is the sandfly, which feeds from dusk to dawn noiselessly and painlessly. Because cutaneous and mucocutaneous leishmaniasis are understudied orphan diseases for which current treatments are less than satisfactory, prevention is the watchword. In endemic areas it’s important to close the windows and make use of air conditioning and ceiling fans when available. When in doubt, it’s advisable to sleep using a bed net treated with permethrin.
Cutaneous larva migrans
This skin eruption is caused by parasitic hookworms, the most common of which in the Americas is Ancylostoma braziliense. The eggs are transmitted through dog and cat feces deposited on soil or sand.
“Avoid laying or sitting on dry sand, even on a towel. And wear shoes,” Dr. Mesinkovska advised.
Among the CDC’s treatment recommendations for cutaneous larva migrans are several agents with poor efficacy and/or considerable side effects. But there is one standout therapy.
“Really, I would say nowadays the easiest thing is one 12-mg oral dose of ivermectin. It’s almost 100% effective,” she said.
Dr. Mesinkovska reported having no financial interests relevant to her talk.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
WAIKOLOA, HAWAII – The Caribbean islands and Central and South America are among the most popular travel destinations for Americans. And some of these visitors will come home harboring unwelcome guests: Infestations that will eventually bring them to a dermatologist’s attention.
“I always tell the residents that if a patient’s country of travel starts with a B – Barbados, Belize, Bolivia, Brazil – it’s going to be something fun,” Natasha A. Mesinkovska, MD, PhD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
According to surveillance conducted by the Centers for Disease Control and Prevention and the International Society for Travel Medicine,
Cutaneous larva migrans is the easiest to diagnosis because it’s a creeping eruption that often migrates at a rate of 1-2 cm per day. Patients with the other disorders often present with a complaint of a common skin condition – described as a pimple, a wart, a patch of sunburn – that just doesn’t go away, according to Dr. Mesinkovska, director of clinical research in the department of dermatology at the University of California, Irvine.
Tungiasis
Tungiasis is caused by the female sand flea, Tunga penetrans, which burrows into the skin, where it lays hundreds of eggs within a matter of a few days. The sand flea is harbored by dogs, cats, pigs, cows, and rats. It’s rare to encounter tungiasis in travelers who’ve spent their time in fancy resorts, ecolodges, or yoga retreats, even if they’ve been parading around with lots of exposed skin. This is a disease of impoverished neighborhoods; hence, affected Americans often have been doing mission work abroad. In tropical areas, tungiasis is a debilitating, mutilating disorder marked by repeated infections, persistent inflammation, fissures, and ulcers.
Treatment involves a topical antiparasitic agent such as ivermectin, metrifonate, or thiabendazole and removal of the flea with sterile forceps or needles. But there is a promising new treatment concept: topical dimethicone, or polydimethylsiloxane. Studies have shown that following application of dimethicone, roughly 80%-90% of sand fleas are dead within 7 days.
“It’s nontoxic and has a purely physical mechanism of action, so resistance is unlikely ... I think it’s going to change the way this condition gets controlled,” Dr. Mesinkovska said.
Myiasis
The differential diagnosis of myiasis includes impetigo, a furuncle, an infected cyst, or a retained foreign body. Myiasis is a cutaneous infestation of the larva of certain flies, among the most notorious of which are the botfly, blowfly, and screwfly. The female fly lays her eggs in hot, humid, shady areas in soil contaminated by feces or urine. The larva can invade unbroken skin instantaneously and painlessly. Then it begins burrowing in. An air hole is always present in the skin so the organism can breathe. Ophthalmomyiasis is common, as are nasal and aural infections, the latter often accompanied by complaints of a crawling sensation inside the ear along with a buzzing noise. To avoid infection, in endemic areas it’s important not to go barefoot or to dry clothes on bushes or on the ground. Treatment entails elimination of the larva. Covering the air hole with petroleum jelly will force it to the surface. There is just one larva per furuncle, so no need for further extensive exploration once that critter has been extracted.
Leishmaniasis
The vector for this protozoan infection is the sandfly, which feeds from dusk to dawn noiselessly and painlessly. Because cutaneous and mucocutaneous leishmaniasis are understudied orphan diseases for which current treatments are less than satisfactory, prevention is the watchword. In endemic areas it’s important to close the windows and make use of air conditioning and ceiling fans when available. When in doubt, it’s advisable to sleep using a bed net treated with permethrin.
Cutaneous larva migrans
This skin eruption is caused by parasitic hookworms, the most common of which in the Americas is Ancylostoma braziliense. The eggs are transmitted through dog and cat feces deposited on soil or sand.
“Avoid laying or sitting on dry sand, even on a towel. And wear shoes,” Dr. Mesinkovska advised.
Among the CDC’s treatment recommendations for cutaneous larva migrans are several agents with poor efficacy and/or considerable side effects. But there is one standout therapy.
“Really, I would say nowadays the easiest thing is one 12-mg oral dose of ivermectin. It’s almost 100% effective,” she said.
Dr. Mesinkovska reported having no financial interests relevant to her talk.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
REPORTING FROM THE SDEF HAWAII DERMATOLOGY SEMINAR
HCV-infected patients in the ED should be tested for advanced liver fibrosis
More than one-third of hepatitis C virus-infected patients in the emergency department (ED) were found to have advanced liver fibrosis and higher mortality, according to the results of a retrospective study of 113 known patients with HCV at a single institution.
As part of an ongoing HCV linkage-to-care (LTC) program, HCV-infected ED patients were retrospectively identified. Components of FIB-4 (a noninvasive serum fibrosis index, which includes age, alanine aminotransferase, aspartate aminotransferase, and platelet count), were abstracted. Patients with an FIB-4 greater than 3.25 were classified with advanced fibrosis and characterized with regard to downstream outcomes at 1 year after enrollment.
The 1-year outcomes after the ED encounter for the 113 patients showed 38 with and 75 patients without advanced fibrosis. Among these, 72 (96%) and 34 (89.5%), respectively, agreed to be linked to HCV care. Ten patients of the total number of patients died within the 1-year follow-up. For those HCV-infected patients with advanced liver fibrosis compared to those without, all-cause mortality was more than fourfold higher, (18.4% [7 patients] vs. 4.0% [3 patients], P = .030), according to Yu-Hsiang Hsieh, PhD, associate professor of emergency medicine at Johns Hopkins University, Baltimore, and his colleagues (Am J Emerg Med. 2019;37[2]:286-90).
“Given the substantial burden of HCV-related illness in urban ED patients nationally, and the recognized fact that EDs are often the only point of contact with the health care system for many of these patients, we propose incorporating FIB-4 based rapid assessment into ED-based HCV screening and LTC programs in order to prioritize LTC for patients with advanced liver fibrosis, as well as routine ED clinical practice,” the researchers concluded.
They reported having no conflicts.
SOURCE: Yu-Hsiang Hsieh Y-H, Am J Emerg Med. 2019;37[2]:286-90.
More than one-third of hepatitis C virus-infected patients in the emergency department (ED) were found to have advanced liver fibrosis and higher mortality, according to the results of a retrospective study of 113 known patients with HCV at a single institution.
As part of an ongoing HCV linkage-to-care (LTC) program, HCV-infected ED patients were retrospectively identified. Components of FIB-4 (a noninvasive serum fibrosis index, which includes age, alanine aminotransferase, aspartate aminotransferase, and platelet count), were abstracted. Patients with an FIB-4 greater than 3.25 were classified with advanced fibrosis and characterized with regard to downstream outcomes at 1 year after enrollment.
The 1-year outcomes after the ED encounter for the 113 patients showed 38 with and 75 patients without advanced fibrosis. Among these, 72 (96%) and 34 (89.5%), respectively, agreed to be linked to HCV care. Ten patients of the total number of patients died within the 1-year follow-up. For those HCV-infected patients with advanced liver fibrosis compared to those without, all-cause mortality was more than fourfold higher, (18.4% [7 patients] vs. 4.0% [3 patients], P = .030), according to Yu-Hsiang Hsieh, PhD, associate professor of emergency medicine at Johns Hopkins University, Baltimore, and his colleagues (Am J Emerg Med. 2019;37[2]:286-90).
“Given the substantial burden of HCV-related illness in urban ED patients nationally, and the recognized fact that EDs are often the only point of contact with the health care system for many of these patients, we propose incorporating FIB-4 based rapid assessment into ED-based HCV screening and LTC programs in order to prioritize LTC for patients with advanced liver fibrosis, as well as routine ED clinical practice,” the researchers concluded.
They reported having no conflicts.
SOURCE: Yu-Hsiang Hsieh Y-H, Am J Emerg Med. 2019;37[2]:286-90.
More than one-third of hepatitis C virus-infected patients in the emergency department (ED) were found to have advanced liver fibrosis and higher mortality, according to the results of a retrospective study of 113 known patients with HCV at a single institution.
As part of an ongoing HCV linkage-to-care (LTC) program, HCV-infected ED patients were retrospectively identified. Components of FIB-4 (a noninvasive serum fibrosis index, which includes age, alanine aminotransferase, aspartate aminotransferase, and platelet count), were abstracted. Patients with an FIB-4 greater than 3.25 were classified with advanced fibrosis and characterized with regard to downstream outcomes at 1 year after enrollment.
The 1-year outcomes after the ED encounter for the 113 patients showed 38 with and 75 patients without advanced fibrosis. Among these, 72 (96%) and 34 (89.5%), respectively, agreed to be linked to HCV care. Ten patients of the total number of patients died within the 1-year follow-up. For those HCV-infected patients with advanced liver fibrosis compared to those without, all-cause mortality was more than fourfold higher, (18.4% [7 patients] vs. 4.0% [3 patients], P = .030), according to Yu-Hsiang Hsieh, PhD, associate professor of emergency medicine at Johns Hopkins University, Baltimore, and his colleagues (Am J Emerg Med. 2019;37[2]:286-90).
“Given the substantial burden of HCV-related illness in urban ED patients nationally, and the recognized fact that EDs are often the only point of contact with the health care system for many of these patients, we propose incorporating FIB-4 based rapid assessment into ED-based HCV screening and LTC programs in order to prioritize LTC for patients with advanced liver fibrosis, as well as routine ED clinical practice,” the researchers concluded.
They reported having no conflicts.
SOURCE: Yu-Hsiang Hsieh Y-H, Am J Emerg Med. 2019;37[2]:286-90.
FROM THE AMERICAN JOURNAL OF EMERGENCY MEDICINE
Measles: 26 new cases reported last week
according to the Centers for Disease Control and Prevention.
On Jan. 31, total measles cases stood at 79, which means that the number of individuals with measles has risen by 61% in just the last 2 weeks. Of the five outbreaks (defined as three or more cases) so far in 2019, three have occurred in New York (57 cases in three counties), one in Texas (8 cases in five counties), and one in Washington (62 cases in two counties), the CDC reported Feb. 18.
The majority of the Washington cases (61 of the 62) have occurred in Clark County, which is located just across the Columbia River from Portland, Ore. Oregon, in turn, has a higher percentage of kindergartners with nonmedical exemptions from vaccination (7.5%) than any other state, the CDC reported in October 2018. Washington’s rate of 3.9% was nearly double the national median of 2.0% for the 2017-2018 school year, while Texas (1.8%) and New York (1.0%) were below it, the CDC said.
In the Pacific Northwest, however, some parents may be changing their minds about vaccinations, according to the New York Times, which reported that “about triple the number of children have been vaccinated this year, compared with the same period in 2018,” in Oregon and southwest Washington.
Individual cases of measles have been reported to the CDC by seven other states: California, Colorado, Connecticut, Georgia, Illinois, Kentucky, and Oregon.
according to the Centers for Disease Control and Prevention.
On Jan. 31, total measles cases stood at 79, which means that the number of individuals with measles has risen by 61% in just the last 2 weeks. Of the five outbreaks (defined as three or more cases) so far in 2019, three have occurred in New York (57 cases in three counties), one in Texas (8 cases in five counties), and one in Washington (62 cases in two counties), the CDC reported Feb. 18.
The majority of the Washington cases (61 of the 62) have occurred in Clark County, which is located just across the Columbia River from Portland, Ore. Oregon, in turn, has a higher percentage of kindergartners with nonmedical exemptions from vaccination (7.5%) than any other state, the CDC reported in October 2018. Washington’s rate of 3.9% was nearly double the national median of 2.0% for the 2017-2018 school year, while Texas (1.8%) and New York (1.0%) were below it, the CDC said.
In the Pacific Northwest, however, some parents may be changing their minds about vaccinations, according to the New York Times, which reported that “about triple the number of children have been vaccinated this year, compared with the same period in 2018,” in Oregon and southwest Washington.
Individual cases of measles have been reported to the CDC by seven other states: California, Colorado, Connecticut, Georgia, Illinois, Kentucky, and Oregon.
according to the Centers for Disease Control and Prevention.
On Jan. 31, total measles cases stood at 79, which means that the number of individuals with measles has risen by 61% in just the last 2 weeks. Of the five outbreaks (defined as three or more cases) so far in 2019, three have occurred in New York (57 cases in three counties), one in Texas (8 cases in five counties), and one in Washington (62 cases in two counties), the CDC reported Feb. 18.
The majority of the Washington cases (61 of the 62) have occurred in Clark County, which is located just across the Columbia River from Portland, Ore. Oregon, in turn, has a higher percentage of kindergartners with nonmedical exemptions from vaccination (7.5%) than any other state, the CDC reported in October 2018. Washington’s rate of 3.9% was nearly double the national median of 2.0% for the 2017-2018 school year, while Texas (1.8%) and New York (1.0%) were below it, the CDC said.
In the Pacific Northwest, however, some parents may be changing their minds about vaccinations, according to the New York Times, which reported that “about triple the number of children have been vaccinated this year, compared with the same period in 2018,” in Oregon and southwest Washington.
Individual cases of measles have been reported to the CDC by seven other states: California, Colorado, Connecticut, Georgia, Illinois, Kentucky, and Oregon.
Enterovirus in at-risk children associated with later celiac disease
“We found a significant association between exposure to enterovirus and subsequent risk of celiac disease,” wrote lead author Christian R. Kahrs of the University of Oslo and his coauthors, adding that “adenovirus was not associated with celiac disease.” The study was published in the BMJ.
From 2001 to 2007, 46,939 newborns in Norway were screened for the HLA-DQ2/DQ8 genotype, which is associated with an increased risk of celiac disease. The genotype was identified in 912 children, and blood and stool sample collection began at 3 months. Children who were still contributing blood samples by 2014-2016 were invited to be screened for celiac disease.
Of the 220 children screened, 25 were diagnosed with celiac disease. Enterovirus was detected in 370 (17%) of the 2,135 stool samples and was more frequent in children who developed celiac disease antibodies than in matched controls (adjusted odds ratio, 1.49; 95% confidence interval, 1.07-2.06; P = .02). There was a significant association between later development of celiac disease and the commonly identified enterovirus A (aOR, 1.62; 95% CI, 1.04-2.53; P = .03) and enterovirus B (aOR, 2.27; 95% CI, 1.33-3.88; P = .003). No adenovirus types were associated with development of celiac disease.
The authors acknowledged their study’s limitations, including the possibility that children might be diagnosed with celiac disease later than the study’s roughly 10-year follow-up and the limited number of children with the disease despite a large number of analyzed samples. They noted that, “given the limited number of cases, we call for corroboration in similar studies and preferably interventional studies to reach conclusions about causality.”
The study was funded by the Research Council of Norway, the Project for the Conceptual Development of Research Organization, and the Norwegian Coeliac Society. Two authors reported grant support from trusts and foundations in Norway and Switzerland; no conflicts of interest were reported.
SOURCE: Kahrs CR et al. BMJ. 2019 Feb 13. doi: 10.1136/bmj.l231.
“We found a significant association between exposure to enterovirus and subsequent risk of celiac disease,” wrote lead author Christian R. Kahrs of the University of Oslo and his coauthors, adding that “adenovirus was not associated with celiac disease.” The study was published in the BMJ.
From 2001 to 2007, 46,939 newborns in Norway were screened for the HLA-DQ2/DQ8 genotype, which is associated with an increased risk of celiac disease. The genotype was identified in 912 children, and blood and stool sample collection began at 3 months. Children who were still contributing blood samples by 2014-2016 were invited to be screened for celiac disease.
Of the 220 children screened, 25 were diagnosed with celiac disease. Enterovirus was detected in 370 (17%) of the 2,135 stool samples and was more frequent in children who developed celiac disease antibodies than in matched controls (adjusted odds ratio, 1.49; 95% confidence interval, 1.07-2.06; P = .02). There was a significant association between later development of celiac disease and the commonly identified enterovirus A (aOR, 1.62; 95% CI, 1.04-2.53; P = .03) and enterovirus B (aOR, 2.27; 95% CI, 1.33-3.88; P = .003). No adenovirus types were associated with development of celiac disease.
The authors acknowledged their study’s limitations, including the possibility that children might be diagnosed with celiac disease later than the study’s roughly 10-year follow-up and the limited number of children with the disease despite a large number of analyzed samples. They noted that, “given the limited number of cases, we call for corroboration in similar studies and preferably interventional studies to reach conclusions about causality.”
The study was funded by the Research Council of Norway, the Project for the Conceptual Development of Research Organization, and the Norwegian Coeliac Society. Two authors reported grant support from trusts and foundations in Norway and Switzerland; no conflicts of interest were reported.
SOURCE: Kahrs CR et al. BMJ. 2019 Feb 13. doi: 10.1136/bmj.l231.
“We found a significant association between exposure to enterovirus and subsequent risk of celiac disease,” wrote lead author Christian R. Kahrs of the University of Oslo and his coauthors, adding that “adenovirus was not associated with celiac disease.” The study was published in the BMJ.
From 2001 to 2007, 46,939 newborns in Norway were screened for the HLA-DQ2/DQ8 genotype, which is associated with an increased risk of celiac disease. The genotype was identified in 912 children, and blood and stool sample collection began at 3 months. Children who were still contributing blood samples by 2014-2016 were invited to be screened for celiac disease.
Of the 220 children screened, 25 were diagnosed with celiac disease. Enterovirus was detected in 370 (17%) of the 2,135 stool samples and was more frequent in children who developed celiac disease antibodies than in matched controls (adjusted odds ratio, 1.49; 95% confidence interval, 1.07-2.06; P = .02). There was a significant association between later development of celiac disease and the commonly identified enterovirus A (aOR, 1.62; 95% CI, 1.04-2.53; P = .03) and enterovirus B (aOR, 2.27; 95% CI, 1.33-3.88; P = .003). No adenovirus types were associated with development of celiac disease.
The authors acknowledged their study’s limitations, including the possibility that children might be diagnosed with celiac disease later than the study’s roughly 10-year follow-up and the limited number of children with the disease despite a large number of analyzed samples. They noted that, “given the limited number of cases, we call for corroboration in similar studies and preferably interventional studies to reach conclusions about causality.”
The study was funded by the Research Council of Norway, the Project for the Conceptual Development of Research Organization, and the Norwegian Coeliac Society. Two authors reported grant support from trusts and foundations in Norway and Switzerland; no conflicts of interest were reported.
SOURCE: Kahrs CR et al. BMJ. 2019 Feb 13. doi: 10.1136/bmj.l231.
FROM THE BMJ
Flu season showing its staying power
Like an unwelcome guest, the 2018-2019 flu season seems to be settling in for a lengthy stay as three more states have reached the highest level of influenza-like illness (ILI) activity, according to the Centers for Disease Control and Prevention.
There are now 21 states at level 10 on the CDC’s 1-10 scale, with the South showing up almost solidly red on the flu activity map for the week ending Feb. 9. Another five states are at levels 8 and 9, bringing the total in the high range to 26 for the week, compared with 24 the previous week, the CDC’s influenza division reported Feb. 15.
National activity, reflected in the proportion of outpatient visits involving ILI, took a step up from 4.3% the week before to 4.8% for the week ending Feb. 9. The national baseline rate is 2.2% for ILI, which the CDC defines “as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.”
Two flu-related pediatric deaths occurred during the week ending Feb. 9, and another four were reported from earlier weeks, which brings the total for the 2018-2019 season to 34, the CDC said. At the same point in last year’s flu season, there had been 84 flu-related deaths in children.
In a separate report, the CDC said that, based on data collected from Nov. 23, 2018 to Feb. 2, 2019, “the influenza vaccine has been 47% effective in preventing medically attended acute respiratory virus infection across all age groups and specifically was 46% effective in preventing medical visits associated with influenza A(H1N1)pdm09.” The effectiveness of the vaccine was 61% for children aged 6 months to 17 years, the CDC said (MMWR. 2019 Feb 15;68[6];135-9).
Flu vaccination during the 2017-2018 season prevented 7.1 million illnesses, 3.7 million medical visits, 109,000 hospitalizations, and 8,000 flu-related deaths, the CDC said, adding that “vaccination has been found to reduce deaths, intensive care unit admissions and length of stay, and overall duration of hospitalization among hospitalized influenza patients.”
Forecasts for the rest of the 2018-2019 season “predict that elevated influenza activity in parts of the United States will continue for several more weeks,” the CDC said.
Like an unwelcome guest, the 2018-2019 flu season seems to be settling in for a lengthy stay as three more states have reached the highest level of influenza-like illness (ILI) activity, according to the Centers for Disease Control and Prevention.
There are now 21 states at level 10 on the CDC’s 1-10 scale, with the South showing up almost solidly red on the flu activity map for the week ending Feb. 9. Another five states are at levels 8 and 9, bringing the total in the high range to 26 for the week, compared with 24 the previous week, the CDC’s influenza division reported Feb. 15.
National activity, reflected in the proportion of outpatient visits involving ILI, took a step up from 4.3% the week before to 4.8% for the week ending Feb. 9. The national baseline rate is 2.2% for ILI, which the CDC defines “as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.”
Two flu-related pediatric deaths occurred during the week ending Feb. 9, and another four were reported from earlier weeks, which brings the total for the 2018-2019 season to 34, the CDC said. At the same point in last year’s flu season, there had been 84 flu-related deaths in children.
In a separate report, the CDC said that, based on data collected from Nov. 23, 2018 to Feb. 2, 2019, “the influenza vaccine has been 47% effective in preventing medically attended acute respiratory virus infection across all age groups and specifically was 46% effective in preventing medical visits associated with influenza A(H1N1)pdm09.” The effectiveness of the vaccine was 61% for children aged 6 months to 17 years, the CDC said (MMWR. 2019 Feb 15;68[6];135-9).
Flu vaccination during the 2017-2018 season prevented 7.1 million illnesses, 3.7 million medical visits, 109,000 hospitalizations, and 8,000 flu-related deaths, the CDC said, adding that “vaccination has been found to reduce deaths, intensive care unit admissions and length of stay, and overall duration of hospitalization among hospitalized influenza patients.”
Forecasts for the rest of the 2018-2019 season “predict that elevated influenza activity in parts of the United States will continue for several more weeks,” the CDC said.
Like an unwelcome guest, the 2018-2019 flu season seems to be settling in for a lengthy stay as three more states have reached the highest level of influenza-like illness (ILI) activity, according to the Centers for Disease Control and Prevention.
There are now 21 states at level 10 on the CDC’s 1-10 scale, with the South showing up almost solidly red on the flu activity map for the week ending Feb. 9. Another five states are at levels 8 and 9, bringing the total in the high range to 26 for the week, compared with 24 the previous week, the CDC’s influenza division reported Feb. 15.
National activity, reflected in the proportion of outpatient visits involving ILI, took a step up from 4.3% the week before to 4.8% for the week ending Feb. 9. The national baseline rate is 2.2% for ILI, which the CDC defines “as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.”
Two flu-related pediatric deaths occurred during the week ending Feb. 9, and another four were reported from earlier weeks, which brings the total for the 2018-2019 season to 34, the CDC said. At the same point in last year’s flu season, there had been 84 flu-related deaths in children.
In a separate report, the CDC said that, based on data collected from Nov. 23, 2018 to Feb. 2, 2019, “the influenza vaccine has been 47% effective in preventing medically attended acute respiratory virus infection across all age groups and specifically was 46% effective in preventing medical visits associated with influenza A(H1N1)pdm09.” The effectiveness of the vaccine was 61% for children aged 6 months to 17 years, the CDC said (MMWR. 2019 Feb 15;68[6];135-9).
Flu vaccination during the 2017-2018 season prevented 7.1 million illnesses, 3.7 million medical visits, 109,000 hospitalizations, and 8,000 flu-related deaths, the CDC said, adding that “vaccination has been found to reduce deaths, intensive care unit admissions and length of stay, and overall duration of hospitalization among hospitalized influenza patients.”
Forecasts for the rest of the 2018-2019 season “predict that elevated influenza activity in parts of the United States will continue for several more weeks,” the CDC said.
Conservatism spreads in prostate cancer
, the United States now has more than 100 measles cases for the year, e-cigarette use reverses progress in reducing teens’ tobacco use, and consider adopting the MESA 10-year coronary heart disease risk calculator.
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, the United States now has more than 100 measles cases for the year, e-cigarette use reverses progress in reducing teens’ tobacco use, and consider adopting the MESA 10-year coronary heart disease risk calculator.
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Apple Podcasts
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, the United States now has more than 100 measles cases for the year, e-cigarette use reverses progress in reducing teens’ tobacco use, and consider adopting the MESA 10-year coronary heart disease risk calculator.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Vaccination and antiviral treatment do not affect stroke risk following shingles
HONOLULU – according to findings from a retrospective study of Medicare beneficiaries with shingles and ischemic stroke.
The findings suggest that primary prevention of shingles through vaccination might be the most effective approach to prevent shingles-associated acute ischemic stroke, said the researchers, who presented the study at the International Stroke Conference sponsored by the American Heart Association.
Almost one in three people in the United States will develop shingles, also known as herpes zoster, in their lifetime, according to the Centers for Disease Control and Prevention. Previous research has not simultaneously examined the effect of shingles vaccination and antiviral treatment following shingles onset on the risk of acute ischemic stroke.
Quanhe Yang, PhD, a senior scientist at the CDC, and his colleagues examined data for 35,186 Medicare fee-for-service beneficiaries who were 66 years or older, diagnosed with shingles during 2008-2014, and diagnosed with acute ischemic stroke within a year of shingles diagnosis. Using a self-controlled case series design, the investigators analyzed the association between shingles and stroke. Dr. Yang and his colleagues estimated the incident rate ratio (IRR) by comparing the incidence of stroke during risk periods (i.e., periods following shingles), compared with control periods. To minimize confounding by age, they restricted their analyses to approximately 365 days from the shingles index date.
To investigate how vaccination against shingles with Zostavax and antiviral treatment following shingles affected stroke risk, the researchers classified beneficiaries into the following four groups: Group 1 had no vaccination and no antiviral treatment (49% of beneficiaries), Group 2 had vaccination only (9%), Group 3 had antiviral treatment only (34%), and Group 4 had vaccination and antiviral treatment (8%). The researchers tested for interaction to examine the changes in IRRs across the four groups.
IRRs for stroke progressively declined as time passed from the index shingles date, from 1.61 at 0-14 days following shingles to 1.35 at 15-30 days, 1.16 at 31-90 days, and 1.05 at 91-180 days. The researchers found no evidence that shingles vaccination and antiviral treatment modified the risk of acute ischemic stroke. The association between shingles and risk for acute ischemic stroke was consistent across age groups (i.e., 66-74 years, 75-84 years, and 85 years or older), sex, and race (i.e., non-Hispanic white, non-Hispanic black, and Hispanic, other).
One of the study’s strengths was that its sample was a large national cohort of Medicare fee-for-service beneficiaries, Dr. Yang said. In addition, the study design eliminated all fixed confounding effects. Potential weaknesses, however, included the fact that herpes zoster diagnosis was based on administrative data and that the vaccine’s efficacy declines over time.
The findings suggest that the importance of following the recommended shingles vaccination protocol in the prevention of shingles, Dr. Yang said. Shingrix, a vaccine that the Food and Drug Administration approved in 2017, prevents shingles with an efficacy greater than 90%, he added.
The investigators reported no funding source or disclosures for this study.
SOURCE: Yang Q et al. Circulation. 2019;50(Suppl_1): Abstract 39
HONOLULU – according to findings from a retrospective study of Medicare beneficiaries with shingles and ischemic stroke.
The findings suggest that primary prevention of shingles through vaccination might be the most effective approach to prevent shingles-associated acute ischemic stroke, said the researchers, who presented the study at the International Stroke Conference sponsored by the American Heart Association.
Almost one in three people in the United States will develop shingles, also known as herpes zoster, in their lifetime, according to the Centers for Disease Control and Prevention. Previous research has not simultaneously examined the effect of shingles vaccination and antiviral treatment following shingles onset on the risk of acute ischemic stroke.
Quanhe Yang, PhD, a senior scientist at the CDC, and his colleagues examined data for 35,186 Medicare fee-for-service beneficiaries who were 66 years or older, diagnosed with shingles during 2008-2014, and diagnosed with acute ischemic stroke within a year of shingles diagnosis. Using a self-controlled case series design, the investigators analyzed the association between shingles and stroke. Dr. Yang and his colleagues estimated the incident rate ratio (IRR) by comparing the incidence of stroke during risk periods (i.e., periods following shingles), compared with control periods. To minimize confounding by age, they restricted their analyses to approximately 365 days from the shingles index date.
To investigate how vaccination against shingles with Zostavax and antiviral treatment following shingles affected stroke risk, the researchers classified beneficiaries into the following four groups: Group 1 had no vaccination and no antiviral treatment (49% of beneficiaries), Group 2 had vaccination only (9%), Group 3 had antiviral treatment only (34%), and Group 4 had vaccination and antiviral treatment (8%). The researchers tested for interaction to examine the changes in IRRs across the four groups.
IRRs for stroke progressively declined as time passed from the index shingles date, from 1.61 at 0-14 days following shingles to 1.35 at 15-30 days, 1.16 at 31-90 days, and 1.05 at 91-180 days. The researchers found no evidence that shingles vaccination and antiviral treatment modified the risk of acute ischemic stroke. The association between shingles and risk for acute ischemic stroke was consistent across age groups (i.e., 66-74 years, 75-84 years, and 85 years or older), sex, and race (i.e., non-Hispanic white, non-Hispanic black, and Hispanic, other).
One of the study’s strengths was that its sample was a large national cohort of Medicare fee-for-service beneficiaries, Dr. Yang said. In addition, the study design eliminated all fixed confounding effects. Potential weaknesses, however, included the fact that herpes zoster diagnosis was based on administrative data and that the vaccine’s efficacy declines over time.
The findings suggest that the importance of following the recommended shingles vaccination protocol in the prevention of shingles, Dr. Yang said. Shingrix, a vaccine that the Food and Drug Administration approved in 2017, prevents shingles with an efficacy greater than 90%, he added.
The investigators reported no funding source or disclosures for this study.
SOURCE: Yang Q et al. Circulation. 2019;50(Suppl_1): Abstract 39
HONOLULU – according to findings from a retrospective study of Medicare beneficiaries with shingles and ischemic stroke.
The findings suggest that primary prevention of shingles through vaccination might be the most effective approach to prevent shingles-associated acute ischemic stroke, said the researchers, who presented the study at the International Stroke Conference sponsored by the American Heart Association.
Almost one in three people in the United States will develop shingles, also known as herpes zoster, in their lifetime, according to the Centers for Disease Control and Prevention. Previous research has not simultaneously examined the effect of shingles vaccination and antiviral treatment following shingles onset on the risk of acute ischemic stroke.
Quanhe Yang, PhD, a senior scientist at the CDC, and his colleagues examined data for 35,186 Medicare fee-for-service beneficiaries who were 66 years or older, diagnosed with shingles during 2008-2014, and diagnosed with acute ischemic stroke within a year of shingles diagnosis. Using a self-controlled case series design, the investigators analyzed the association between shingles and stroke. Dr. Yang and his colleagues estimated the incident rate ratio (IRR) by comparing the incidence of stroke during risk periods (i.e., periods following shingles), compared with control periods. To minimize confounding by age, they restricted their analyses to approximately 365 days from the shingles index date.
To investigate how vaccination against shingles with Zostavax and antiviral treatment following shingles affected stroke risk, the researchers classified beneficiaries into the following four groups: Group 1 had no vaccination and no antiviral treatment (49% of beneficiaries), Group 2 had vaccination only (9%), Group 3 had antiviral treatment only (34%), and Group 4 had vaccination and antiviral treatment (8%). The researchers tested for interaction to examine the changes in IRRs across the four groups.
IRRs for stroke progressively declined as time passed from the index shingles date, from 1.61 at 0-14 days following shingles to 1.35 at 15-30 days, 1.16 at 31-90 days, and 1.05 at 91-180 days. The researchers found no evidence that shingles vaccination and antiviral treatment modified the risk of acute ischemic stroke. The association between shingles and risk for acute ischemic stroke was consistent across age groups (i.e., 66-74 years, 75-84 years, and 85 years or older), sex, and race (i.e., non-Hispanic white, non-Hispanic black, and Hispanic, other).
One of the study’s strengths was that its sample was a large national cohort of Medicare fee-for-service beneficiaries, Dr. Yang said. In addition, the study design eliminated all fixed confounding effects. Potential weaknesses, however, included the fact that herpes zoster diagnosis was based on administrative data and that the vaccine’s efficacy declines over time.
The findings suggest that the importance of following the recommended shingles vaccination protocol in the prevention of shingles, Dr. Yang said. Shingrix, a vaccine that the Food and Drug Administration approved in 2017, prevents shingles with an efficacy greater than 90%, he added.
The investigators reported no funding source or disclosures for this study.
SOURCE: Yang Q et al. Circulation. 2019;50(Suppl_1): Abstract 39
REPORTING FROM ISC 2019
Key clinical point: After a patient develops shingles, prior vaccination or treatment with antiviral medication does not change the risk of acute ischemic stroke.
Major finding: Stroke incidence increased by 61% within 14 days after shingles onset.
Study details: A self-controlled case series of 35,186 Medicare beneficiaries with shingles and acute ischemic stroke.
Disclosures: The authors reported no funding source or disclosures for this study.
Source: Yang Q et al. Circulation. 2019;50(Suppl_1), Abstract 39
Adult HIV patients should receive standard vaccinations, with caveats
Patients infected with HIV have an increased risk of mortality and morbidity from diseases that are preventable with vaccines. Undervaccination of these patients poses a major concern, according to a literature review of the vaccine response in the adult patient with HIV published in The American Journal of Medicine.
Despite the fact that data are limited, patients infected with HIV are advised to receive their age-specific and risk group−based vaccines, according to Firas El Chaer, MD, of the University of Maryland, Baltimore, and his colleague.
HIV patients are of particular concern regarding vaccination, because, despite the use of retroviral therapy, CD4+ T-lymphocytes in individuals infected with HIV remain lower than in those without HIV. In addition, HIV causes an inappropriate response to B-cell stimulation, which results in suboptimal primary and secondary response to vaccination, according to Dr. El Chaer and his colleague. Despite this and initial concerns about vaccine safety in this population, it is now recommended that adult patients infected with HIV receive their age-specific and risk group−based vaccines, they stated.
Inactivated or subunit vaccines
Haemophilus influenzae type b vaccine is not recommended under current guidelines for individuals older than age 18 with HIV infection, unless they have a clinical indication.
Vaccination against hepatitis A virus is recommended for HIV-infected patients who are hepatitis A virus seronegative and have chronic liver disease, men who have sex with men, intravenous drug users, and travelers to endemic regions. However, research has shown that the immunogenicity of the vaccine is lower in patients with HIV than in uninfected individuals. It was found that the CD4 count at the time of vaccination, not the CD4 low point, was the major predictor of the immune response.
Patients coinfected with HIV and hepatitis B virus have an 8-fold and 19-fold increase in mortality, respectively, compared with either virus monoinfection. Although vaccination is recommended, the optimal hepatitis B virus vaccination schedule in patients with HIV remains controversial, according to the authors. They indicated that new strategies to improve hepatitis B virus vaccine immunogenicity for those infected with HIV are needed.
Individuals infected with HIV have been found to have a higher risk of human papillomavirus (HPV) infection. The safety and immunogenicity results and prospect of benefits has led to a consensus on the benefit of vaccinating HIV-infected patients who meet the HPV vaccine age criteria, the authors indicated.
With regard to standard flu vaccinations: “An annual inactivated influenza vaccine is recommended during the influenza season for all adult individuals with HIV; however, a live attenuated influenza vaccine is contraindicated in this population,” according to the review.
Patients with HIV have a more than 10-fold increased risk of invasive meningococcal disease, compared with the general population, with the risk being particularly higher in those individuals with CD4 counts less than 200 cells/mm3 and in men who have sex with men in cities with meningococcal outbreaks. For these reasons, the “quadrivalent meningococcal vaccine is recommended for all patients with HIV regardless of their CD4 count, with 2-dose primary series at least 2 months apart and with a booster every 5 years.”
Pneumonia is known to be especially dangerous in the HIV-infected population. With regard to pneumonia vaccination, the 13-valent pneumococcal conjugate vaccine is recommended for all patients with HIV, regardless of their CD4 cell counts. According to Dr. El Chaer and his colleague, it should be followed by the 23-valent pneumococcal polysaccharide vaccine at least 8 weeks later as a prime-boost regimen, preferably when CD4 counts are greater than 200 cells/mm3 and in patients receiving ART.
“Tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccines are recommended once for all individuals infected with HIV, regardless of the CD4 count, with a tetanus toxoid and diphtheria toxoid booster every 10 years,” according to the review.
Live vaccines
Live vaccines are a concerning issue for HIV-infected adults and recommendations for use are generally tied to the CD4 T-cell count. The measles, mumps, and rubella vaccine seems to be safe in patients infected with HIV with a CD4 count greater than 200 cells/mm3, according to Dr. El Chaer and his colleague. Similarly, patients with HIV with CD4 counts greater than 200 cells/mm3 and no evidence of documented immunity to varicella should receive the varicella vaccine.
In contrast, the live, attenuated varicella zoster virus vaccine is not recommended for patients infected with HIV, and it is contraindicated if CD4 count is less than 200 cells/mm3. Recently, a herpes zoster subunit vaccine (HZ/su) was tested in a phase 1/2a randomized, placebo-controlled study and was found to be safe and immunogenic regardless of CD4 count, although it has not yet been given a specific recommendation for immunocompromised patients.
“With the widespread use of ART resulting in better HIV control, ,” the authors concluded.
The study was not sponsored. Dr. El Chaer and his colleague reported that they had no conflicts.
SOURCE: El Chaer F et al. Am J Med. 2019. doi: 10.1016/j.amjmed.2018.12.011.
Patients infected with HIV have an increased risk of mortality and morbidity from diseases that are preventable with vaccines. Undervaccination of these patients poses a major concern, according to a literature review of the vaccine response in the adult patient with HIV published in The American Journal of Medicine.
Despite the fact that data are limited, patients infected with HIV are advised to receive their age-specific and risk group−based vaccines, according to Firas El Chaer, MD, of the University of Maryland, Baltimore, and his colleague.
HIV patients are of particular concern regarding vaccination, because, despite the use of retroviral therapy, CD4+ T-lymphocytes in individuals infected with HIV remain lower than in those without HIV. In addition, HIV causes an inappropriate response to B-cell stimulation, which results in suboptimal primary and secondary response to vaccination, according to Dr. El Chaer and his colleague. Despite this and initial concerns about vaccine safety in this population, it is now recommended that adult patients infected with HIV receive their age-specific and risk group−based vaccines, they stated.
Inactivated or subunit vaccines
Haemophilus influenzae type b vaccine is not recommended under current guidelines for individuals older than age 18 with HIV infection, unless they have a clinical indication.
Vaccination against hepatitis A virus is recommended for HIV-infected patients who are hepatitis A virus seronegative and have chronic liver disease, men who have sex with men, intravenous drug users, and travelers to endemic regions. However, research has shown that the immunogenicity of the vaccine is lower in patients with HIV than in uninfected individuals. It was found that the CD4 count at the time of vaccination, not the CD4 low point, was the major predictor of the immune response.
Patients coinfected with HIV and hepatitis B virus have an 8-fold and 19-fold increase in mortality, respectively, compared with either virus monoinfection. Although vaccination is recommended, the optimal hepatitis B virus vaccination schedule in patients with HIV remains controversial, according to the authors. They indicated that new strategies to improve hepatitis B virus vaccine immunogenicity for those infected with HIV are needed.
Individuals infected with HIV have been found to have a higher risk of human papillomavirus (HPV) infection. The safety and immunogenicity results and prospect of benefits has led to a consensus on the benefit of vaccinating HIV-infected patients who meet the HPV vaccine age criteria, the authors indicated.
With regard to standard flu vaccinations: “An annual inactivated influenza vaccine is recommended during the influenza season for all adult individuals with HIV; however, a live attenuated influenza vaccine is contraindicated in this population,” according to the review.
Patients with HIV have a more than 10-fold increased risk of invasive meningococcal disease, compared with the general population, with the risk being particularly higher in those individuals with CD4 counts less than 200 cells/mm3 and in men who have sex with men in cities with meningococcal outbreaks. For these reasons, the “quadrivalent meningococcal vaccine is recommended for all patients with HIV regardless of their CD4 count, with 2-dose primary series at least 2 months apart and with a booster every 5 years.”
Pneumonia is known to be especially dangerous in the HIV-infected population. With regard to pneumonia vaccination, the 13-valent pneumococcal conjugate vaccine is recommended for all patients with HIV, regardless of their CD4 cell counts. According to Dr. El Chaer and his colleague, it should be followed by the 23-valent pneumococcal polysaccharide vaccine at least 8 weeks later as a prime-boost regimen, preferably when CD4 counts are greater than 200 cells/mm3 and in patients receiving ART.
“Tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccines are recommended once for all individuals infected with HIV, regardless of the CD4 count, with a tetanus toxoid and diphtheria toxoid booster every 10 years,” according to the review.
Live vaccines
Live vaccines are a concerning issue for HIV-infected adults and recommendations for use are generally tied to the CD4 T-cell count. The measles, mumps, and rubella vaccine seems to be safe in patients infected with HIV with a CD4 count greater than 200 cells/mm3, according to Dr. El Chaer and his colleague. Similarly, patients with HIV with CD4 counts greater than 200 cells/mm3 and no evidence of documented immunity to varicella should receive the varicella vaccine.
In contrast, the live, attenuated varicella zoster virus vaccine is not recommended for patients infected with HIV, and it is contraindicated if CD4 count is less than 200 cells/mm3. Recently, a herpes zoster subunit vaccine (HZ/su) was tested in a phase 1/2a randomized, placebo-controlled study and was found to be safe and immunogenic regardless of CD4 count, although it has not yet been given a specific recommendation for immunocompromised patients.
“With the widespread use of ART resulting in better HIV control, ,” the authors concluded.
The study was not sponsored. Dr. El Chaer and his colleague reported that they had no conflicts.
SOURCE: El Chaer F et al. Am J Med. 2019. doi: 10.1016/j.amjmed.2018.12.011.
Patients infected with HIV have an increased risk of mortality and morbidity from diseases that are preventable with vaccines. Undervaccination of these patients poses a major concern, according to a literature review of the vaccine response in the adult patient with HIV published in The American Journal of Medicine.
Despite the fact that data are limited, patients infected with HIV are advised to receive their age-specific and risk group−based vaccines, according to Firas El Chaer, MD, of the University of Maryland, Baltimore, and his colleague.
HIV patients are of particular concern regarding vaccination, because, despite the use of retroviral therapy, CD4+ T-lymphocytes in individuals infected with HIV remain lower than in those without HIV. In addition, HIV causes an inappropriate response to B-cell stimulation, which results in suboptimal primary and secondary response to vaccination, according to Dr. El Chaer and his colleague. Despite this and initial concerns about vaccine safety in this population, it is now recommended that adult patients infected with HIV receive their age-specific and risk group−based vaccines, they stated.
Inactivated or subunit vaccines
Haemophilus influenzae type b vaccine is not recommended under current guidelines for individuals older than age 18 with HIV infection, unless they have a clinical indication.
Vaccination against hepatitis A virus is recommended for HIV-infected patients who are hepatitis A virus seronegative and have chronic liver disease, men who have sex with men, intravenous drug users, and travelers to endemic regions. However, research has shown that the immunogenicity of the vaccine is lower in patients with HIV than in uninfected individuals. It was found that the CD4 count at the time of vaccination, not the CD4 low point, was the major predictor of the immune response.
Patients coinfected with HIV and hepatitis B virus have an 8-fold and 19-fold increase in mortality, respectively, compared with either virus monoinfection. Although vaccination is recommended, the optimal hepatitis B virus vaccination schedule in patients with HIV remains controversial, according to the authors. They indicated that new strategies to improve hepatitis B virus vaccine immunogenicity for those infected with HIV are needed.
Individuals infected with HIV have been found to have a higher risk of human papillomavirus (HPV) infection. The safety and immunogenicity results and prospect of benefits has led to a consensus on the benefit of vaccinating HIV-infected patients who meet the HPV vaccine age criteria, the authors indicated.
With regard to standard flu vaccinations: “An annual inactivated influenza vaccine is recommended during the influenza season for all adult individuals with HIV; however, a live attenuated influenza vaccine is contraindicated in this population,” according to the review.
Patients with HIV have a more than 10-fold increased risk of invasive meningococcal disease, compared with the general population, with the risk being particularly higher in those individuals with CD4 counts less than 200 cells/mm3 and in men who have sex with men in cities with meningococcal outbreaks. For these reasons, the “quadrivalent meningococcal vaccine is recommended for all patients with HIV regardless of their CD4 count, with 2-dose primary series at least 2 months apart and with a booster every 5 years.”
Pneumonia is known to be especially dangerous in the HIV-infected population. With regard to pneumonia vaccination, the 13-valent pneumococcal conjugate vaccine is recommended for all patients with HIV, regardless of their CD4 cell counts. According to Dr. El Chaer and his colleague, it should be followed by the 23-valent pneumococcal polysaccharide vaccine at least 8 weeks later as a prime-boost regimen, preferably when CD4 counts are greater than 200 cells/mm3 and in patients receiving ART.
“Tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccines are recommended once for all individuals infected with HIV, regardless of the CD4 count, with a tetanus toxoid and diphtheria toxoid booster every 10 years,” according to the review.
Live vaccines
Live vaccines are a concerning issue for HIV-infected adults and recommendations for use are generally tied to the CD4 T-cell count. The measles, mumps, and rubella vaccine seems to be safe in patients infected with HIV with a CD4 count greater than 200 cells/mm3, according to Dr. El Chaer and his colleague. Similarly, patients with HIV with CD4 counts greater than 200 cells/mm3 and no evidence of documented immunity to varicella should receive the varicella vaccine.
In contrast, the live, attenuated varicella zoster virus vaccine is not recommended for patients infected with HIV, and it is contraindicated if CD4 count is less than 200 cells/mm3. Recently, a herpes zoster subunit vaccine (HZ/su) was tested in a phase 1/2a randomized, placebo-controlled study and was found to be safe and immunogenic regardless of CD4 count, although it has not yet been given a specific recommendation for immunocompromised patients.
“With the widespread use of ART resulting in better HIV control, ,” the authors concluded.
The study was not sponsored. Dr. El Chaer and his colleague reported that they had no conflicts.
SOURCE: El Chaer F et al. Am J Med. 2019. doi: 10.1016/j.amjmed.2018.12.011.
FROM THE AMERICAN JOURNAL OF MEDICINE
Key clinical point: Undervaccination is too common among HIV-infected patients.
Major finding: Data on vaccine effectiveness in HIV patients are limited, but do not contraindicate the need for vaccination.
Study details: Literature review of immunogenicity and vaccine efficacy in HIV-infected adults.
Disclosures: The study was unsponsored and the authors reported they had no conflicts.
Source: El Chaer F et al. Am J Med. 2019. doi: 10.1016/j.amjmed.2018.12.011.
Adenovirus: More than just another viral illness
The mother of three looked tired and little worried. She wasn’t one to bring her kids to the pediatrician’s office with every minor illness, but her youngest had 3 days of fever, runny nose, cough, and little of her normal energy.
The pediatrician entered the room and smiled sympathetically.
“We ran tests for flu and RSV [respiratory syncytial virus] and it’s neither of those so. ...”
“So it’s just a virus that we don’t routinely test for and it’s going to need to run its course,” the mother finished his sentence. She knew the drill.
Before the doctor could leave the room though, the mother had one more question. “You don’t think it could be adenovirus do you?”
Most years, influenza and RSV command center stage, and adenovirus is relegated to the wings. It is not so much lack of disease or morbidity, but rather lack of recognition. Yes, we all learned in medical school that it is a cause of epidemic keratoconjunctivitis, but many adenoviral infections are clinically indistinguishable from infections caused by other viruses. Common symptoms – fever, cough, sore throat, and malaise – overlap with those caused by influenza. Like rhinovirus, adenovirus can cause common cold symptoms. Like RSV, it can cause bronchiolitis. Just like parainfluenza, it can cause croup. It can cause a pertussislike syndrome with prolonged cough, and enteric adenoviruses, especially types 40 and 41, cause gastroenteritis that mimics norovirus or rotavirus infection.
Testing for adenovirus is not readily available or routine in most pediatricians’ offices, and while many hospitals and reference labs offer adenovirus polymerase chain reaction testing as part of a comprehensive respiratory virus panel, the test can be expensive and unlikely to change management in most ambulatory patients. This makes it difficult to count the number of adenoviruses annually.
This winter though, adenovirus was in the news ... repeatedly. In November 2018, CBS News reported that a University of Maryland freshman had died of an adenovirus-related illness. The family of Olivia Paregol told reporters that she was being treated for Crohn’s disease. Immune suppression is one recognized risk factor for more severe adenoviral disease; underlying heart and lung disease are others. Testing at the Centers for Disease Control and Prevention revealed that the student and several others on campus were infected with adenovirus type 7, a strain that has been associated with outbreaks of acute, severe respiratory illness in military recruits. As of Jan. 24, 2019, university officials reported 42 confirmed cases of adenovirus in University of Maryland students, 13 of which were confirmed as adenovirus 7.
Adenovirus type 7 also caused an outbreak at a pediatric long-term care facility in New Jersey late last year. Between Sept. 26 and Nov. 11, 2018, 36 residents and 1 staff member became ill. Eleven individuals died. In an unrelated outbreak at a second pediatric long-term care facility, 17 residents were affected between Oct. 20 and Dec. 10, 2018. Adenovirus 3 was identified and all children recovered.
Between October 2013 and July 2014, public health officials in Oregon identified an increase in adenoviral infections in people with respiratory illness. Sixty-nine percent were hospitalized (136/198), 31% needed intensive care, and 18% were mechanically ventilated. Multiple types of adenovirus were recovered but the most common was adenovirus 7 (Emerg Infect Dis. 2016. doi: 10.3201/eid2206.151898).
Depending on your perspective, measures to prevent the spread of adenovirus are elegantly simple, evidence-based, public health intervention or maddeningly little more than common sense. Wash your hands often with soap and water. Avoid touching your eyes, mouth, and nose with unwashed hands. Avoid close contact with people who are sick. The latter is easier if those who are sick stay home. Prior to the start of the most recent academic semester at the University of Maryland, university officials urged students who were sick not to return to campus but to stay at home to rest and recover. Those who fell ill on campus were urged to return home via nonpublic transportation if possible. Those who stayed on campus were advised to stay in their living spaces and clean high-touch surfaces with bleach. Like other nonenveloped viruses, adenovirus is not easily destroyed by many commonly used disinfectants. Under ideal conditions, it can survive on surfaces – remaining infectious – for up to 3 months.
Back at the pediatrician’s office, “We need an adenovirus vaccine,” the mother said as she picked up her child and headed for the door.
There is, in fact, a live oral vaccine that protects against adenovirus types 4 and 7. It is only approved for use in United States military personnel aged 17-50 years and it is given to all recruits as soon as they enter basic training. It works too. Before vaccine was available, up to 80% of recruits became infected during their initial training, half of those developing significant illness and a quarter being hospitalized. When the current vaccine was introduced in 2011, there was a 100-fold decrease in adenovirus-related disease burden (from 5.8 to 0.02 cases per 1,000 person-weeks, P less than .0001). That translates to 1 death, 1,100-2,700 hospitalizations and 13,000 febrile illnesses prevented each year (Clin Infect Dis. 2014 Oct 1. doi: 10.1093/cid/ciu507).
Some experts have suggested that adenovirus vaccine could be useful in civilian populations, too, but I question what the public reception would be. We have safe influenza vaccines that reduce the need for hospitalization and reduce mortality from influenza, but we still can’t convince some people to immunize themselves and their children. In the last 4 years, flu vaccination rates among children have remained just shy of 60% and adult rates are even lower. Collectively, we don’t seem to be ready to relinquish – or at least diminish – the annual suffering that goes with flu. I have to wonder if the same would be true for adenovirus.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].
The mother of three looked tired and little worried. She wasn’t one to bring her kids to the pediatrician’s office with every minor illness, but her youngest had 3 days of fever, runny nose, cough, and little of her normal energy.
The pediatrician entered the room and smiled sympathetically.
“We ran tests for flu and RSV [respiratory syncytial virus] and it’s neither of those so. ...”
“So it’s just a virus that we don’t routinely test for and it’s going to need to run its course,” the mother finished his sentence. She knew the drill.
Before the doctor could leave the room though, the mother had one more question. “You don’t think it could be adenovirus do you?”
Most years, influenza and RSV command center stage, and adenovirus is relegated to the wings. It is not so much lack of disease or morbidity, but rather lack of recognition. Yes, we all learned in medical school that it is a cause of epidemic keratoconjunctivitis, but many adenoviral infections are clinically indistinguishable from infections caused by other viruses. Common symptoms – fever, cough, sore throat, and malaise – overlap with those caused by influenza. Like rhinovirus, adenovirus can cause common cold symptoms. Like RSV, it can cause bronchiolitis. Just like parainfluenza, it can cause croup. It can cause a pertussislike syndrome with prolonged cough, and enteric adenoviruses, especially types 40 and 41, cause gastroenteritis that mimics norovirus or rotavirus infection.
Testing for adenovirus is not readily available or routine in most pediatricians’ offices, and while many hospitals and reference labs offer adenovirus polymerase chain reaction testing as part of a comprehensive respiratory virus panel, the test can be expensive and unlikely to change management in most ambulatory patients. This makes it difficult to count the number of adenoviruses annually.
This winter though, adenovirus was in the news ... repeatedly. In November 2018, CBS News reported that a University of Maryland freshman had died of an adenovirus-related illness. The family of Olivia Paregol told reporters that she was being treated for Crohn’s disease. Immune suppression is one recognized risk factor for more severe adenoviral disease; underlying heart and lung disease are others. Testing at the Centers for Disease Control and Prevention revealed that the student and several others on campus were infected with adenovirus type 7, a strain that has been associated with outbreaks of acute, severe respiratory illness in military recruits. As of Jan. 24, 2019, university officials reported 42 confirmed cases of adenovirus in University of Maryland students, 13 of which were confirmed as adenovirus 7.
Adenovirus type 7 also caused an outbreak at a pediatric long-term care facility in New Jersey late last year. Between Sept. 26 and Nov. 11, 2018, 36 residents and 1 staff member became ill. Eleven individuals died. In an unrelated outbreak at a second pediatric long-term care facility, 17 residents were affected between Oct. 20 and Dec. 10, 2018. Adenovirus 3 was identified and all children recovered.
Between October 2013 and July 2014, public health officials in Oregon identified an increase in adenoviral infections in people with respiratory illness. Sixty-nine percent were hospitalized (136/198), 31% needed intensive care, and 18% were mechanically ventilated. Multiple types of adenovirus were recovered but the most common was adenovirus 7 (Emerg Infect Dis. 2016. doi: 10.3201/eid2206.151898).
Depending on your perspective, measures to prevent the spread of adenovirus are elegantly simple, evidence-based, public health intervention or maddeningly little more than common sense. Wash your hands often with soap and water. Avoid touching your eyes, mouth, and nose with unwashed hands. Avoid close contact with people who are sick. The latter is easier if those who are sick stay home. Prior to the start of the most recent academic semester at the University of Maryland, university officials urged students who were sick not to return to campus but to stay at home to rest and recover. Those who fell ill on campus were urged to return home via nonpublic transportation if possible. Those who stayed on campus were advised to stay in their living spaces and clean high-touch surfaces with bleach. Like other nonenveloped viruses, adenovirus is not easily destroyed by many commonly used disinfectants. Under ideal conditions, it can survive on surfaces – remaining infectious – for up to 3 months.
Back at the pediatrician’s office, “We need an adenovirus vaccine,” the mother said as she picked up her child and headed for the door.
There is, in fact, a live oral vaccine that protects against adenovirus types 4 and 7. It is only approved for use in United States military personnel aged 17-50 years and it is given to all recruits as soon as they enter basic training. It works too. Before vaccine was available, up to 80% of recruits became infected during their initial training, half of those developing significant illness and a quarter being hospitalized. When the current vaccine was introduced in 2011, there was a 100-fold decrease in adenovirus-related disease burden (from 5.8 to 0.02 cases per 1,000 person-weeks, P less than .0001). That translates to 1 death, 1,100-2,700 hospitalizations and 13,000 febrile illnesses prevented each year (Clin Infect Dis. 2014 Oct 1. doi: 10.1093/cid/ciu507).
Some experts have suggested that adenovirus vaccine could be useful in civilian populations, too, but I question what the public reception would be. We have safe influenza vaccines that reduce the need for hospitalization and reduce mortality from influenza, but we still can’t convince some people to immunize themselves and their children. In the last 4 years, flu vaccination rates among children have remained just shy of 60% and adult rates are even lower. Collectively, we don’t seem to be ready to relinquish – or at least diminish – the annual suffering that goes with flu. I have to wonder if the same would be true for adenovirus.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].
The mother of three looked tired and little worried. She wasn’t one to bring her kids to the pediatrician’s office with every minor illness, but her youngest had 3 days of fever, runny nose, cough, and little of her normal energy.
The pediatrician entered the room and smiled sympathetically.
“We ran tests for flu and RSV [respiratory syncytial virus] and it’s neither of those so. ...”
“So it’s just a virus that we don’t routinely test for and it’s going to need to run its course,” the mother finished his sentence. She knew the drill.
Before the doctor could leave the room though, the mother had one more question. “You don’t think it could be adenovirus do you?”
Most years, influenza and RSV command center stage, and adenovirus is relegated to the wings. It is not so much lack of disease or morbidity, but rather lack of recognition. Yes, we all learned in medical school that it is a cause of epidemic keratoconjunctivitis, but many adenoviral infections are clinically indistinguishable from infections caused by other viruses. Common symptoms – fever, cough, sore throat, and malaise – overlap with those caused by influenza. Like rhinovirus, adenovirus can cause common cold symptoms. Like RSV, it can cause bronchiolitis. Just like parainfluenza, it can cause croup. It can cause a pertussislike syndrome with prolonged cough, and enteric adenoviruses, especially types 40 and 41, cause gastroenteritis that mimics norovirus or rotavirus infection.
Testing for adenovirus is not readily available or routine in most pediatricians’ offices, and while many hospitals and reference labs offer adenovirus polymerase chain reaction testing as part of a comprehensive respiratory virus panel, the test can be expensive and unlikely to change management in most ambulatory patients. This makes it difficult to count the number of adenoviruses annually.
This winter though, adenovirus was in the news ... repeatedly. In November 2018, CBS News reported that a University of Maryland freshman had died of an adenovirus-related illness. The family of Olivia Paregol told reporters that she was being treated for Crohn’s disease. Immune suppression is one recognized risk factor for more severe adenoviral disease; underlying heart and lung disease are others. Testing at the Centers for Disease Control and Prevention revealed that the student and several others on campus were infected with adenovirus type 7, a strain that has been associated with outbreaks of acute, severe respiratory illness in military recruits. As of Jan. 24, 2019, university officials reported 42 confirmed cases of adenovirus in University of Maryland students, 13 of which were confirmed as adenovirus 7.
Adenovirus type 7 also caused an outbreak at a pediatric long-term care facility in New Jersey late last year. Between Sept. 26 and Nov. 11, 2018, 36 residents and 1 staff member became ill. Eleven individuals died. In an unrelated outbreak at a second pediatric long-term care facility, 17 residents were affected between Oct. 20 and Dec. 10, 2018. Adenovirus 3 was identified and all children recovered.
Between October 2013 and July 2014, public health officials in Oregon identified an increase in adenoviral infections in people with respiratory illness. Sixty-nine percent were hospitalized (136/198), 31% needed intensive care, and 18% were mechanically ventilated. Multiple types of adenovirus were recovered but the most common was adenovirus 7 (Emerg Infect Dis. 2016. doi: 10.3201/eid2206.151898).
Depending on your perspective, measures to prevent the spread of adenovirus are elegantly simple, evidence-based, public health intervention or maddeningly little more than common sense. Wash your hands often with soap and water. Avoid touching your eyes, mouth, and nose with unwashed hands. Avoid close contact with people who are sick. The latter is easier if those who are sick stay home. Prior to the start of the most recent academic semester at the University of Maryland, university officials urged students who were sick not to return to campus but to stay at home to rest and recover. Those who fell ill on campus were urged to return home via nonpublic transportation if possible. Those who stayed on campus were advised to stay in their living spaces and clean high-touch surfaces with bleach. Like other nonenveloped viruses, adenovirus is not easily destroyed by many commonly used disinfectants. Under ideal conditions, it can survive on surfaces – remaining infectious – for up to 3 months.
Back at the pediatrician’s office, “We need an adenovirus vaccine,” the mother said as she picked up her child and headed for the door.
There is, in fact, a live oral vaccine that protects against adenovirus types 4 and 7. It is only approved for use in United States military personnel aged 17-50 years and it is given to all recruits as soon as they enter basic training. It works too. Before vaccine was available, up to 80% of recruits became infected during their initial training, half of those developing significant illness and a quarter being hospitalized. When the current vaccine was introduced in 2011, there was a 100-fold decrease in adenovirus-related disease burden (from 5.8 to 0.02 cases per 1,000 person-weeks, P less than .0001). That translates to 1 death, 1,100-2,700 hospitalizations and 13,000 febrile illnesses prevented each year (Clin Infect Dis. 2014 Oct 1. doi: 10.1093/cid/ciu507).
Some experts have suggested that adenovirus vaccine could be useful in civilian populations, too, but I question what the public reception would be. We have safe influenza vaccines that reduce the need for hospitalization and reduce mortality from influenza, but we still can’t convince some people to immunize themselves and their children. In the last 4 years, flu vaccination rates among children have remained just shy of 60% and adult rates are even lower. Collectively, we don’t seem to be ready to relinquish – or at least diminish – the annual suffering that goes with flu. I have to wonder if the same would be true for adenovirus.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].
Dengue antibodies may reduce Zika infection risk
Previous dengue exposure may confer a protective effect against Zika virus infection, according to a paper published in Science.
In a prospective cohort study, researchers followed 1,453 urban residents in Salvador, Brazil, to assess the impact of the 2015 Zika virus outbreak in the region. Data on dengue immunity was available for 642 of these individuals.
Overall, 73% of the cohort were seropositive for Zika virus. However, the frequency of seropositivity varied significantly by location, from 29% in a valley in the northeastern sector of the study area to 83% in the southeast corner; the authors wrote that this was consistent with some form of acquired immunity “blunting the efficiency of transmission.”
When researchers looked at the relationship between prior immunity to the dengue virus and the risk of Zika infection, they found that each doubling of total IgG titers against dengue NS1 was associated with a 9% reduction in the risk of Zika virus infection.
Individuals in the highest tertile of dengue IgG titers showed a 44% reduction in the odds of Zika seropositivity, compared with individuals with no or low dengue IgG titers, while those in the middle tertile of dengue IgG titer had a 38% reduction.
“These findings provide empirical support for the hypothesis that accumulated immunity drove ZIKV [Zika virus] to local extinction by reducing the efficiency of transmission,” wrote Isabel Rodriguez-Barraquer, MD, PhD, from the department of medicine at the University of California, San Francisco, and her coauthors.
Individuals who were infected with the Zika virus but had high dengue IgG titers were significantly less likely to exhibit fever with viral infection, but had the same risk of developing rash as those with low or no IgG titers.
Researchers also examined the link between a subclass of IgG antibodies that are associated with more recent exposure to dengue virus – within the prior 6 months – and the risk of Zika virus infection. In contrast, they found that the levels of this subclass of antibodies, known as IgG3, were positively associated with an increased risk of Zika virus infection. Each doubling in IgG3 levels was associated with a 23% increase in the odds of being positive for Zika.
“This positive association might reflect an immune profile, in individuals who have experienced a recent DENV [dengue virus] infection, that is associated with having a greater risk of a subsequent ZIKV infection,” the authors wrote. “Alternatively, it is also possible that higher levels of IgG3 are a proxy for frequent DENV exposure and thus greater risk of infection by Aedes aegypti–transmitted viruses.”
The study was supported by Yale University, a number of Brazilian research organizations, the Research Support Foundation for the State of São Paulo, CuraZika Foundation, Wellcome Trust, and the National Institutes of Health. Three authors are listed on a patent application related to the work, and one reported an honoraria from Sanofi-Pasteur.
SOURCE: Rodriguez-Barraquer I et al. Science. 2019;36:607-10.
Previous dengue exposure may confer a protective effect against Zika virus infection, according to a paper published in Science.
In a prospective cohort study, researchers followed 1,453 urban residents in Salvador, Brazil, to assess the impact of the 2015 Zika virus outbreak in the region. Data on dengue immunity was available for 642 of these individuals.
Overall, 73% of the cohort were seropositive for Zika virus. However, the frequency of seropositivity varied significantly by location, from 29% in a valley in the northeastern sector of the study area to 83% in the southeast corner; the authors wrote that this was consistent with some form of acquired immunity “blunting the efficiency of transmission.”
When researchers looked at the relationship between prior immunity to the dengue virus and the risk of Zika infection, they found that each doubling of total IgG titers against dengue NS1 was associated with a 9% reduction in the risk of Zika virus infection.
Individuals in the highest tertile of dengue IgG titers showed a 44% reduction in the odds of Zika seropositivity, compared with individuals with no or low dengue IgG titers, while those in the middle tertile of dengue IgG titer had a 38% reduction.
“These findings provide empirical support for the hypothesis that accumulated immunity drove ZIKV [Zika virus] to local extinction by reducing the efficiency of transmission,” wrote Isabel Rodriguez-Barraquer, MD, PhD, from the department of medicine at the University of California, San Francisco, and her coauthors.
Individuals who were infected with the Zika virus but had high dengue IgG titers were significantly less likely to exhibit fever with viral infection, but had the same risk of developing rash as those with low or no IgG titers.
Researchers also examined the link between a subclass of IgG antibodies that are associated with more recent exposure to dengue virus – within the prior 6 months – and the risk of Zika virus infection. In contrast, they found that the levels of this subclass of antibodies, known as IgG3, were positively associated with an increased risk of Zika virus infection. Each doubling in IgG3 levels was associated with a 23% increase in the odds of being positive for Zika.
“This positive association might reflect an immune profile, in individuals who have experienced a recent DENV [dengue virus] infection, that is associated with having a greater risk of a subsequent ZIKV infection,” the authors wrote. “Alternatively, it is also possible that higher levels of IgG3 are a proxy for frequent DENV exposure and thus greater risk of infection by Aedes aegypti–transmitted viruses.”
The study was supported by Yale University, a number of Brazilian research organizations, the Research Support Foundation for the State of São Paulo, CuraZika Foundation, Wellcome Trust, and the National Institutes of Health. Three authors are listed on a patent application related to the work, and one reported an honoraria from Sanofi-Pasteur.
SOURCE: Rodriguez-Barraquer I et al. Science. 2019;36:607-10.
Previous dengue exposure may confer a protective effect against Zika virus infection, according to a paper published in Science.
In a prospective cohort study, researchers followed 1,453 urban residents in Salvador, Brazil, to assess the impact of the 2015 Zika virus outbreak in the region. Data on dengue immunity was available for 642 of these individuals.
Overall, 73% of the cohort were seropositive for Zika virus. However, the frequency of seropositivity varied significantly by location, from 29% in a valley in the northeastern sector of the study area to 83% in the southeast corner; the authors wrote that this was consistent with some form of acquired immunity “blunting the efficiency of transmission.”
When researchers looked at the relationship between prior immunity to the dengue virus and the risk of Zika infection, they found that each doubling of total IgG titers against dengue NS1 was associated with a 9% reduction in the risk of Zika virus infection.
Individuals in the highest tertile of dengue IgG titers showed a 44% reduction in the odds of Zika seropositivity, compared with individuals with no or low dengue IgG titers, while those in the middle tertile of dengue IgG titer had a 38% reduction.
“These findings provide empirical support for the hypothesis that accumulated immunity drove ZIKV [Zika virus] to local extinction by reducing the efficiency of transmission,” wrote Isabel Rodriguez-Barraquer, MD, PhD, from the department of medicine at the University of California, San Francisco, and her coauthors.
Individuals who were infected with the Zika virus but had high dengue IgG titers were significantly less likely to exhibit fever with viral infection, but had the same risk of developing rash as those with low or no IgG titers.
Researchers also examined the link between a subclass of IgG antibodies that are associated with more recent exposure to dengue virus – within the prior 6 months – and the risk of Zika virus infection. In contrast, they found that the levels of this subclass of antibodies, known as IgG3, were positively associated with an increased risk of Zika virus infection. Each doubling in IgG3 levels was associated with a 23% increase in the odds of being positive for Zika.
“This positive association might reflect an immune profile, in individuals who have experienced a recent DENV [dengue virus] infection, that is associated with having a greater risk of a subsequent ZIKV infection,” the authors wrote. “Alternatively, it is also possible that higher levels of IgG3 are a proxy for frequent DENV exposure and thus greater risk of infection by Aedes aegypti–transmitted viruses.”
The study was supported by Yale University, a number of Brazilian research organizations, the Research Support Foundation for the State of São Paulo, CuraZika Foundation, Wellcome Trust, and the National Institutes of Health. Three authors are listed on a patent application related to the work, and one reported an honoraria from Sanofi-Pasteur.
SOURCE: Rodriguez-Barraquer I et al. Science. 2019;36:607-10.
FROM SCIENCE
Key clinical point: Higher dengue antibody titers are associated with a lower risk of Zika virus infection.
Major finding: The highest tertile of dengue antibody titers was associated with a 44% reduction in the risk of Zika seropositivity.
Study details: A prospective cohort study of 1,453 residents in Salvador, Brazil.
Disclosures: The study was supported by Yale University, a number of Brazilian research organizations, the Research Support Foundation for the State of São Paulo, CuraZika Foundation, Wellcome Trust, and the National Institutes of Health. Three authors are listed on a patent application related to the work, and one reported an honoraria from Sanofi-Pasteur.
Source: Rodriguez-Barraquer I et al. Science. 2019;36:607-10.