Celia Aitken

Reduction of Natural Killer but Not Effector CD8 T Lymphoyctes in Three Consecutive Cases of Severe/Lethal H1N1/09 Influenza A Virus Infection

Background The cause of severe disease in some patients infected with pandemic influenza A virus is unclear. Methodology/Principal Findings We present the cellular immunology profile in the blood, and detailed clinical (and post-mortem) findings of three patients with rapidly progressive infection, including a pregnant patient who died. The striking finding is of reduction in natural killer (NK) cells but preservation of activated effector CD8 T lymphocytes; with viraemia in the patient who had no NK cells. Comparison with control groups suggests that the reduction of NK cells is unique to these severely ill patients. Conclusion/Significance Our report shows markedly reduced NK cells in the three patients that we sampled and raises the hypothesis that NK may have a more significant role than T lymphocytes in controlling viral burden when the host is confronted with a new influenza A virus subtype.

Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions.

Background Government policy has precipitated recent changes in the provision of harm reduction interventions – injecting equipment provision (IEP) and opiate substitution therapy (OST) – for people who inject drugs (PWID) in Scotland. We sought to examine the potential impact of these changes on hepatitis C virus (HCV) transmission among PWID. Methods and Findings We used a framework to triangulate different types of evidence: ‘group-level/ecological’ and ‘individual-level’. Evidence was primarily generated from bio-behavioural cross-sectional surveys of PWID, undertaken during 2008-2012. Individuals in the window period (1–2 months) where the virus is present, but antibodies have not yet been formed, were considered to have recent infection. The survey data were supplemented with service data on the provision of injecting equipment and OST. Ecological analyses examined changes in intervention provision, self-reported intervention uptake, self-reported risk behaviour and HCV incidence; individual-level analyses investigated relationships within the pooled survey data. Nearly 8,000 PWID were recruited in the surveys. We observed a decline in HCV incidence, per 100 person-years, from 13.6 (95% CI: 8.1–20.1) in 2008–09 to 7.3 (3.0–12.9) in 2011–12; a period during which increases in the coverage of OST and IEP, and decreases in the frequency of injecting and sharing of injecting equipment, were observed. Individual-level evidence demonstrated that combined high coverage of needles/syringes and OST were associated with reduced risk of recent HCV in analyses that were unweighted (AOR 0.29, 95%CI 0.11–0.74) and weighted for frequency of injecting (AORw 0.05, 95%CI 0.01–0.18). We estimate the combination of harm reduction interventions may have averted 1400 new HCV infections during 2008–2012. Conclusions This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

Management of cytomegalovirus infection in haemopoietic stem cell transplantation

● Cytomegalovirus (CMV) infection and CMV diseaseshould be diagnosed according to established, interna-tionally accepted, standardized criteria (Grade 1C).● Risk-adapted patient assessment should inform clinicalmanagement (Grade 1B).● All potential haemopoietic stem cell transplantation(HSCT) recipients should be tested for the presence ofCMV IgG antibody at diagnosis (Grade 1C).● Once optimum human leucocyte antigen (HLA) match-ing has been performed, a CMV IgG-negative donorshould be chosen for a CMV IgG-negative recipient anda CMV IgG-positive donor should be chosen for a CMVIgG-positive recipient when possible (Grade 1A).● Donors or recipients who are initially found to be CMVIgG-negative should be retested pre-transplant toexclude primary CMV infection (Grade 1C).● Apparent CMV seroconversion in potential allograftrecipients who have received unscreened blood productsshould be actively investigated to exclude passive acqui-sition of antibody (Grade 1C)● Any CMV IgG-negative HSCT recipient transplantedfrom a CMV IgG-negative donor who develops CMVinfection post-transplant must be reported to the SeriousHazards of Transfusion (SHOT) scheme (Grade 1C).● Primary prophylaxis with ganciclovir is not generallyrecommended as toxicity outweighs efficacy in HSCTpatients (Grade 1B).● Primary prophylaxis with aciclovir or valaciclovir canbe deployed but only in conjunction with appropriatemonitoring of CMV in blood (Grade 1B).● Valaciclovir or valganciclovir are valid treatmentoptions for secondary prophylaxis with appropriatemonitoring of CMV in blood (Grade 1C).● Intravenous immunoglobulin is not recommended forprophylaxis of CMV infection (Grade 1A).● Real time quantitative polymerase chain reaction (PCR)is the preferred choice for monitoring CMV DNA levelsin HSCT patients (Grade 1B).● All diagnostic laboratories should deploy the CMVinternational standard to allow viral loads to becompared between centres (Grade 1C).● Monitoring of CMV load should be undertaken atleast weekly for the first 3 months post-HSCT (Grade2C).● CMV viral load monitoring should continue for 6-12 months if the patient has chronic graft-versus-hostdisease (GvHD) or prolonged T-cell immunodeficiency(Grade 1B).● Each transplant centre should have a risk-adapted policydetailing threshold values for treatment of CMV infec-tion, taking into account patient factors and PCR meth-odology (Grade 2C).● Ganciclovir is recommended as first line pre-emptivetherapy for CMV in HSCT patients (Grade 1A).● Oral valganciclovir is a valid alternative when gastroin-testinal absorption is normal or only minimallyimpaired (Grade 1A).● Foscarnet is recommended as an alternative first-lineagent if neutropenia is present or for ganciclovir treat-ment failure (Grade 1A).

Influenza A community-acquired pneumonia in East London infants and young children

Background. Community-acquired pneumonia (CAP) is common in young children, but there are few data in Europe on influenza A virus as a cause of childhood CAP. The aim of this study was to determine the relative contributions of different etiologic agents to CAP in children. Methods. This was a 6-month prospective study of pediatric accident and emergency and general practice consultations with a diagnosis of CAP. Nasopharyngeal aspirates for viral immunofluorescence and PCR studies and blood cultures for bacterial studies were taken from 51 children with symptoms, signs and chest radiographic features that satisfied a diagnosis of pneumonia. Results. An etiologic agent was isolated from 25 patients (49%). A viral cause was identified in 22 patients (43%), and influenza A virus and respiratory syncytial virus (RSV) were detected in 16 and 18% of all cases, respectively. Only four patients (8%) had a positive bacterial blood culture; three had Streptococcus pneumoniae and one had Neisseria meningitidis W135. Mycoplasma pneumoniae was detected in 2 children, and mixed infections were detected in 5 (10%). The use of viral PCR increased the detection rate of influenza A virus by 100%. Conclusion. Influenza A virus caused more than one-third of all viral CAP cases, a rate comparable with that of RSV CAP. Viral PCR doubled the diagnostic yield of influenza A virus. The clinical burden of influenza A CAP was comparable with that of RSV CAP, as measured by the duration of fever, hospital stay and total duration of illness.

Cytokine responses in patients with mild or severe influenza A(H1N1)pdm09

BACKGROUND Influenza virus affects millions of people worldwide each year. More severe infection occurs in the elderly, very young and immunocompromised. In 2009, a new variant of swine origin (influenza A(H1N1)pdm09 virus) emerged that produced severe disease in young healthy adults. OBJECTIVES The aim of this study was to determine whether cytokine concentrations are associated with clinical outcome in patients infected influenza A(H1N1)pdm09 virus. STUDY DESIGN Plasma concentration of 32 cytokines and growth factors were measured using a multiplex bead immunoassay and conventional ELISA in four patient groups. Patients with severe and mild influenza A(H1N1)pdm09 virus infection, rhinovirus infection and healthy volunteers were investigated. In addition, serial samples of respiratory secretions from five patients with severe influenza A(H1N1)pdm09 virus infection were examined. RESULTS The majority of cytokines measured were elevated in patients with viral respiratory infections compared to the healthy controls. Concentrations of IL-6, IL-10, IL-15, IP-10, IL-2R, HGF, ST2 and MIG were significantly higher (p<0.05) and EGF significantly lower (p=0.0001) in patients with severe influenza A(H1N1)pdm09 virus infection compared to those with mild influenza A(H1N1)pdm09 virus and rhinovirus infection. CONCLUSIONS A number of cytokines were found to be substantially elevated in patients with severe influenza A(H1N1)pdm09 virus infection. This supports and extends other published work suggesting a role for proinflammatory cytokines in influenza-induced lung pathology. Interestingly, EGF was significantly lower in patients with severe infection suggesting it is actively suppressed. As EGF has a role in role in cell proliferation and tissue repair, it may protect the lung from host or virus mediated damage.

Rise in testing and diagnosis associated with Scotland's Action Plan on Hepatitis C and introduction of dried blood spot testing

Background A key aim of the Hepatitis C Action Plan for Scotland was to reduce the undiagnosed population through awareness-raising activities, for general practitioners and those at risk, and the introduction of dried blood spot (DBS) sampling in community drug services to overcome barriers to testing. This study evaluates the impact of these activities on testing and diagnosis. Methods Data on hepatitis C virus (HCV) testing undertaken between January 1999 and December 2011 in Scotlands four largest health boards were analysed. Segmented regression analysis was used to examine changes in testing following the (1) launch of the Action Plan and (2) introduction of DBS testing. Results Between the pre-Action Plan and Action Plan periods, increases were observed in the average number of HCV tests (19 058–29 045), positive tests (1993–2405) and new diagnoses (1221–1367). Since July 2009, 26% of new diagnoses were made in drug services. The trend in the number of positive tests was raised during the Action Plan, compared to pre-Action Plan, particularly in drug services (rate ratio (RR)=1.4, p<0.001) and prisons (RR=1.2, p<0.001); no change was observed in general practice. Following introduction of DBS testing, there was a 3-fold increase in testing (RR=3.5, p<0.001) and 12-fold increase in positives (RR=12.1, p<0.001) in drug services. Conclusions The introduction of DBS sampling in community drug services has made an appreciable contribution to efforts to diagnose the HCV-infected population in Scotland. These findings are important to other countries, with injecting-related HCV epidemics, needing to scale-up testing/case-finding initiatives.

Hepatitis C reinfection following treatment induced viral clearance among people who have injected drugs.

BACKGROUND Although people who inject drugs (PWID) are an important group to receive Hepatitis C Virus (HCV) antiviral therapy, initiation onto treatment remains low. Concerns over reinfection may make clinicians reluctant to treat this group. We examined the risk of HCV reinfection among a cohort of PWID (encompassing all those reporting a history of injecting drug use) from Scotland who achieved a sustained virological response (SVR). METHODS Clinical and laboratory data were used to monitor RNA testing among PWID who attained SVR following therapy between 2000 and 2009. Data were linked to morbidity and mortality records. Follow-up began one year after completion of therapy, ending on 31st December, 2012. Frequency of RNA testing during follow-up was calculated and the incidence of HCV reinfection estimated. Cox proportional hazards regression was used to examine factors associated with HCV reinfection. RESULTS Among 448 PWID with a SVR, 277 (61.8%) were tested during follow-up, median 4.5 years; 191 (69%) received one RNA test and 86 (31%) received at least two RNA tests. There were seven reinfections over 410 person years generating a reinfection rate of 1.7/100py (95% CI 0.7-3.5). For PWID who have been hospitalised for an opiate or injection related cause post SVR (11%), the risk of HCV reinfection was greater [AHR=12.9, 95% CI 2.2-76.0, p=0.002] and the reinfection rate was 5.7/100py (95% CI 1.8-13.3). CONCLUSION PWID who have been tested, following SVR, for HCV in Scotland appear to be at a low risk of reinfection. Follow-up and monitoring of this population are warranted as treatment is offered more widely.

Uptake of hepatitis C specialist services and treatment following diagnosis by dried blood spot in Scotland

BACKGROUND Dried blood spot (DBS) testing for hepatitis C (HCV) was introduced to Scotland in 2009. This minimally invasive specimen provides an alternative to venipuncture and can overcome barriers to testing in people who inject drugs (PWID). OBJECTIVES The objective of this study was to determine rates and predictors of: exposure to HCV, attendance at specialist clinics and anti-viral treatment initiation among the DBS tested population in Scotland. STUDY DESIGN DBS testing records were deterministically linked to the Scottish HCV Clinical database prior to logistic regression analysis. RESULTS In the first two years of usage in Scotland, 1322 individuals were tested by DBS of which 476 were found to have an active HCV infection. Linkage analysis showed that 32% had attended a specialist clinic within 12 months of their specimen collection date and 18% had begun anti-viral therapy within 18 months of their specimen collection date. A significantly reduced likelihood of attendance at a specialist clinic was evident amongst younger individuals (<35 years), those of unknown ethnic origin and those not reporting injecting drug use as a risk factor. CONCLUSION We conclude that DBS testing in non-clinical settings has the potential to increase diagnosis and, with sufficient support, treatment of HCV infection among PWID.

Prevalence of HCV NS3 pre-treatment resistance associated amino acid variants within a Scottish cohort

Highlights • Prevalence of HCV NS3 resistance-associated amino acid variants (RAV) was investigated.• Sanger sequencing was performed on a protease inhibitor treatment-naïve Scottish cohort (n = 146).• Overall 23.29% had a detectable RAV in the NS3 region; Q80K was the most prevalent.• Only 2.74% patients had more than one RAV.• The study highlighted the need for Q80K sequencing prior to simeprevir treatment.

First confirmed case of Crimean-Congo haemorrhagic fever in the UK

In October, 2012, a 38-year-old Afghan man presented to an emergency department in Glasgow, UK, 2 h after returning on a fl ight from Kabul via Dubai, after a 3 week stay in Afghanistan, where he had attended a wedding in Samangan Province. His symptoms had started 5 days before presentation and included fever, epigastric pain, bloody diarrhoea, and haematemesis. On examination he was languid but orientated, with physical observations within normal limits. Conjunctival suff usion was present and a haematoma rapidly developed at the site of venepuncture. Initial blood results showed transaminitis and thrombocytopenia (appendix). The patient was transferred to the Brownlee Centre for Infectious Diseases, Glasgow, and isolated in a negative-pressure room. Formal viral haemorrhagic fever risk assessment was implemented according to the 2012 guidelines published by the Advisory Committee on Dangerous Pathogens (ACDP); the patient reported no contact with ticks (the vector of Crimean-Congo haemorrhagic fever [CCHF]) or with animals and was therefore classifi ed as “possibility of viral haemorrhagic fever” (appendix). Infection control measures were applied in line with ACDP guidance. He was discussed with the Rare and Imported Pathogens Department (RIPD) of the Health Protection Agency, Greater Glasgow and Clyde Public Health Department, and the High Security Infectious Diseases Unit at the Royal Free Hospital, London. Samples of blood and urine were sent by courier to the RIPD laboratory at Porton Down, UK, for rapid CCHF virus testing by PCR: laboratory con fi rmation of the diagnosis of CCHF was made within 36 h of the patient’s presentation. After diagnosis, the patient’s wife discovered that during the Afghan wedding ceremony her husband had been close to a slaughtered calf, the probable source of infection. Despite intravenous ribavirin, the patient’s condition deteriorated, with fl uctuating Glasgow Coma Scale scores, and rising respiratory rate and pulse. 60 h after initial presentation, in keeping with national guidelines, he was transported to Glasgow International Airport by the Scottish Ambulance Service Special Operations Response Team and a dedicated RAF Air Transport Isolator team, and then transferred to the Royal Free Hospital High Security Infectious Diseases Unit in an RAF Hercules and dedicated ambulance where he was managed in a modi fi ed Trexler isolator (Putlock Chimney Systems Ltd, Whitchurch, UK) which provided a sealed environment and pro tection for the staff caring for him. During the fl ight further clinical deterioration was evident including anuria, vascular leak, and a decerebrate response to pain suggesting an intracerebral haemorrhage. Over the subsequent 24 h, he deteriorated further and developed pulmonary haemorrhage. The patient died 96 h after initial presentation. Viral haemorrhagic fever is a rare diagnosis in nonendemic areas and we report the fi rst confi rmed case of CCHF in the UK. Caused by a tick-borne virus, CCHF virus is endemic to more than 30 countries in Central and south western Asia, south eastern Europe, and Africa. Human beings can be infected from tick bites, contact with body fl uid, or, as suspected in the present case, contact with tissue from viraemic livestock. After a variable incubation period (average 2–7 days), fever and myalgia develop; haemorrhagic features start around the fourth day of illness, with mortality rate up to 30%. With increasing international travel to viral haemorrhagic fever endemic areas, clinicians in all countries must maintain a high index of suspicion for cases. In this instance, following infectious diseases consultant assessment, the possibility of viral haemor rhagic fever was recognised within 6 h of presentation, and the diagnosis of CCHF confi rmed rapidly. Consequently, the patient was promptly isolated. Surveillance has not identifi ed any onward transmission. This situation contrasts with multiple previously reported incidences of CCHF where late diagnosis and gaps in infection control procedure have been associated with nosocomial outbreaks. The case also highlights the value of a collateral history and asking about contact with blood from animal carcasses. Our patient is the fi rst confi rmed case of viral haemorrhagic fever in the UK since the 2012 guidelines for management of human infectious diseases of high consequence were published.