Patrick Obermeier

Early detection of influenza A and B infection in infants and children using conventional and fluorescence-based rapid testing

BACKGROUND The appropriate management of infants and children with influenza depends on the accurate and timely diagnosis, ideally at the point of care (POC). OBJECTIVES To evaluate the use of simultaneous RSV/influenza rapid testing with QuickVue™ test strips as well as (the use of) novel, fluorescence-based, rapid influenza antigen testing (SOFIA™) in infants and children with influenza-like illness (ILI). STUDY DESIGN The Study was conducted in a real-time surveillance program at the Charité Department of Pediatrics in collaboration with the National Reference Centre for Influenza at the Robert Koch Institute (RKI) in Berlin, Germany (Charité Influenza-Like Disease=ChILD Cohort). RESULTS During the 2010/2011 influenza season, 395 infants and children were simultaneously tested using QuickVue™ FluA&B and RSV10 rapid tests at POC compared to independent RT-PCR. Sensitivities were 62.7/67.8% for Influenza/RSV overall, but highest in infants <1 year with 76.0/76.2%. The evaluation of the fluorescence-based rapid test SOFIA™ with frozen laboratory samples (derived from the 2008/2009 and 2010/2011 national surveillance) yielded sensitivities of 97.7/86.7/86.7/81.7% for influenza A(H1N1)pdm09/A(H3N2)/B-Victoria/B-Yamagata in samples with CT values <34, and 80.2/79.8/67.5/62.5% for all CT values combined. The same method used at POC with 649 consecutive ChILD patients in 2011-2012 yielded sensitivity/specificity/PPV/NPV values of 78.9/99.7/96.6/97.3%. Again, sensitivities were highest in infants (85.7%) and small children <2 years (88%). CONCLUSIONS Fluorescence-based rapid antigen testing provides a highly sensitive and specific tool for POC diagnostics of acute influenza in the paediatric age group, especially in infants and small children <2 years, when viral loads are at their peak and treatment decisions are imminent.

Human Parechovirus Infections Associated with Seizures and Rash in Infants and Toddlers.

Background: Systematic investigations assessing the clinical impact of human parechovirus (HPeV) disease are sparse. Noninvasive stool samples may be useful for targeted hospital-based surveillance. Methods: In the context of a quality management program, all hospitalized children fulfilling predefined case criteria for central nervous system (CNS) infection/inflammation underwent standardized neurologic examinations. Stool samples were collected for HPeV and enterovirus (EV) polymerase chain reaction and molecular typing at the National Reference Center. Results: From October 2010 to December 2012, stool samples of 284 patients with suspected CNS infection/inflammation were tested yielding 12 (4.2%) HPeV+ samples and 43 (15.1%) EV+ samples. HPeV-positive samples included HPeV-1, HPeV-3 and HPeV-6. No additional pathogens were identified in routine care. HPeV-positive patients were significantly younger (P < 0.001) and more likely to present with seizures (P = 0.001) and rash (P < 0.0001) when compared with HPeV-negative patients. Conclusions: In hospitalized children younger than 4 years presenting with suspected CNS infection/inflammation, seizures and/or rash, HPeV should be considered in the differential diagnosis. Large-scale public health surveillance may be indicated.

Evaluation of novel second-generation RSV and influenza rapid tests at the point of care.

Acute respiratory infections represent common pediatric emergencies. Infection control warrants immediate and accurate diagnoses. In the past, first-generation respiratory syncytial virus (RSV) rapid tests (strip tests) have shown suboptimal sensitivities. In 2013, the Food and Drug Administration licensed a second-generation RSV rapid test providing user-independent readouts (SOFIA™-RSV) using automated fluorescence assay technology known to yield superior results with influenza rapid testing. We are reporting the first point-of-care evaluation of the SOFIA™-RSV rapid test. In the Charité Influenza-Like Disease Cohort, 686 nasopharyngeal samples were tested in parallel with SOFIA™-RSV and SOFIA™-Influenza A+B. Compared to real-time PCR, SOFIA™-RSV sensitivities/specificities were 78.6%/93.9%, respectively (SOFIA™-Influenza A: 80.6%/99.3%). Performance was greatest in patients below 2 years of age with a test sensitivity of 81.8%. RSV sensitivities were highest (85%) in the first 2 days of illness and with nasopharyngeal compared to nasal swabs (P=0.055, McNemars test). Second-generation RSV and influenza rapid testing provides highly accurate results facilitating timely patient cohortation and management.

Recombinant Enterovirus A71 Subgenogroup C1 Strains, Germany, 2015

To the Editor: Enterovirus A71 (EV-A71) strains circulate worldwide, and numerous outbreaks have been reported from Asia, Australia, Europe, and America (1). Symptomatic infections range from mild febrile illness or characteristic diseases such as hand, foot and mouth disease to severe neurologic disorders such as meningitis/encephalitis and acute flaccid paralysis. EV-A71 infections are usually asymptomatic and self-limiting but can also result in life-threatening complications such as pulmonary edema and cause death, predominantly in children <5 years of age. On the basis of viral protein 1 (VP1) sequences, 3 genogroups (A, B, C), including different subgenogroups (B0–B5, C1–C5), have been defined (2,3). Additional genogroups (D, E, F, G) have been proposed (4,5). In Europe, C1 and C2 strains have circulated predominantly within the past 2 decades, and recent introduction of C4 strains has been reported (6,7). Within subgenogroup C1, a lineage is replaced by the subsequent lineage over time (8).

Quantitative influenza follow-up testing (QIFT)--a novel biomarker for the monitoring of disease activity at the point-of-care.

Background Influenza infections induce considerable disease burden in young children. Biomarkers for the monitoring of disease activity at the point-of-care (POC) are currently lacking. Recent methodologies for fluorescence-based rapid testing have been developed to provide improved sensitivities with the initial diagnosis. The present study aims to explore the utility of second-generation rapid testing during longitudinal follow-up of influenza patients (Rapid Influenza Follow-up Testing = RIFT). Signal/control fluorescent readouts (Quantitative Influenza Follow-up Testing = QIFT) are evaluated as a potential biomarker for the monitoring of disease activity at the POC. Methods and Findings RIFT (SOFIA) and QIFT were performed at the POC and compared to blinded RT-PCR at the National Reference Centre for Influenza. From 10/2011-4/2013, a total of 2048 paediatric cases were studied prospectively; 273 cases were PCR-confirmed for influenza. During follow-up, RIFT results turned negative either prior to PCR (68%), or simultaneously (30%). The first negative RIFT occurred after a median of 8 days with a median virus load (VL) of 5.6×10∧3 copies/ml and cycle threshold of 37, with no evidence of viral rebound. Binning analysis revealed that QIFT differentiated accurately between patients with low, medium and high viral titres. QIFT increase/decrease showed 88% agreement (sensitivity = 52%, specificity = 95%) with VL increase/decrease, respectively. QIFT-based viral clearance estimates showed similar values compared to PCR-based estimates. Variations in viral clearance rates were lower in treated compared to untreated patients. The study was limited by use of non-invasive, semi-quantitative nasopharyngeal samples. VL measurements below the limit of detection could not be quantified reliably. Conclusions During follow-up, RIFT provides a first surrogate measure for influenza disease activity. A “switch” from positive to negative values may indicate a drop in viral load below a critical threshold, where rebound is no longer expected. QIFT may provide a useful tool for the monitoring of disease burden and viral clearance at the POC.

The impact of the parent-physician relationship on parental vaccine safety perceptions.

In times of declining immunization rates among children in many countries and an increasing threat of potentially vaccine-preventable diseases, there is a strong need for new strategies to improve trust in vaccinations and acceptance of recommendations, especially in parents of infants and children. A survey to evaluate vaccination acceptance has been conducted in Vienna, Austria, based on a US CDC survey, applying a cross-sectional approach with districts and public as well as private kindergartens and preschools as selection base. The survey aimed to investigate the impact of parent satisfaction with, and overall trust in the physician on vaccine acceptance, as well as the impact of quality and completeness of safety information delivered during the vaccination consultation. Overall 1101 parents, predominantly (84.2%) mothers, participated in the survey. The majority (82.7%) of participants had a generally positive view concerning childhood vaccination. However, 25.1% refused at least one of the recommended vaccinations. In multivariate analysis, confidence in vaccinations was significantly influenced by education (lower confidence at higher levels of education), gender (higher confidence in females), and positively associated with trust in physician, smooth vaccination procedure, and information about vaccine risks. Similar results were obtained for compliance with recommended vaccinations with information about vaccine benefits being the most important predictor. This large survey indicates an important role of the physician in communicating balanced information about benefits and risks associated with childhood vaccinations. A trustworthy parent-physician relationship is crucial for vaccination decisions of parents.

Enabling Precision Medicine With Digital Case Classification at the Point-of-Care.

Infectious and inflammatory diseases of the central nervous system are difficult to identify early. Case definitions for aseptic meningitis, encephalitis, myelitis, and acute disseminated encephalomyelitis (ADEM) are available, but rarely put to use. The VACC-Tool (Vienna Vaccine Safety Initiative Automated Case Classification-Tool) is a mobile application enabling immediate case ascertainment based on consensus criteria at the point-of-care. The VACC-Tool was validated in a quality management program in collaboration with the Robert-Koch-Institute. Results were compared to ICD-10 coding and retrospective analysis of electronic health records using the same case criteria. Of 68,921 patients attending the emergency room in 10/2010–06/2013, 11,575 were hospitalized, with 521 eligible patients (mean age: 7.6 years) entering the quality management program. Using the VACC-Tool at the point-of-care, 180/521 cases were classified successfully and 194/521 ruled out with certainty. Of the 180 confirmed cases, 116 had been missed by ICD-10 coding, 38 misclassified. By retrospective application of the same case criteria, 33 cases were missed. Encephalitis and ADEM cases were most likely missed or misclassified. The VACC-Tool enables physicians to ask the right questions at the right time, thereby classifying cases consistently and accurately, facilitating translational research. Future applications will alert physicians when additional diagnostic procedures are required.

Educating parents about the vaccination status of their children: A user-centered mobile application.

Parents are often uncertain about the vaccination status of their children. In times of vaccine hesitancy, vaccination programs could benefit from active patient participation. The Vaccination App (VAccApp) was developed by the Vienna Vaccine Safety Initiative, enabling parents to learn about the vaccination status of their children, including 25 different routine, special indication and travel vaccines listed in the WHO Immunization Certificate of Vaccination (WHO-ICV). Between 2012 and 2014, the VAccApp was validated in a hospital-based quality management program in Berlin, Germany, in collaboration with the Robert Koch Institute. Parents of 178 children were asked to transfer the immunization data of their children from the WHO-ICV into the VAccApp. The respective WHO-ICV was photocopied for independent, professional data entry (gold standard). Demonstrating the status quo in vaccine information reporting, a Recall Group of 278 parents underwent structured interviews for verbal immunization histories, without the respective WHO-ICV. Only 9% of the Recall Group were able to provide a complete vaccination status; on average 39% of the questions were answered correctly. Using the WHO-ICV with the help of the VAccApp resulted in 62% of parents providing a complete vaccination status; on average 95% of the questions were answered correctly. After using the VAccApp, parents were more likely to remember key aspects of the vaccination history. User-friendly mobile applications empower parents to take a closer look at the vaccination record, thereby taking an active role in providing accurate vaccination histories. Parents may become motivated to ask informed questions and to keep vaccinations up-to-date.

Acute Disseminated Encephalomyelitis After Human Parechovirus Infection.

Background: Acute disseminated encephalomyelitis (ADEM) is an inflammatory, demyelinating disease occurring several weeks after viral infection. Enteroviruses have been described as potential triggers of ADEM, but the closely related parechoviruses have not. The objective of the study is to assess the prevalence and disease presentation of ADEM after parechovirus infection in a syndromic surveillance program for pediatric infection/inflammation of the central nervous system (CNS). Methods: The surveillance was conducted at the Charité Department of Pediatrics in Berlin, Germany, from November 2010 to November 2014. All hospitalized children meeting predefined case criteria underwent highly standardized prospective clinical assessments based on the published case definitions, including for ADEM. Stool samples were independently analyzed by enterovirus and parechovirus real-time polymerase chain reaction at the Robert Koch Institute. Results: Of 105,557 patients screened, 774 (0.7%) fulfilled entry criteria for CNS infection/inflammation, with 114 cases ascertained as ADEM. Parechoviruses were detected in 2.5% of patients with CNS infection/inflammation, including 1 case fulfilling ADEM case criteria with the highest level of diagnostic certainty. Conclusions: We report a first case of ADEM after parechovirus infection in a 5-year-old female presenting with acute hemiparesis 2 weeks after a respiratory illness. Parechovirus disease should be included in the differential diagnosis of ADEM.

Genome Sequence of Novel Human Parechovirus Type 17

ABSTRACT Human parechoviruses (HPeV) circulate worldwide, causing a broad variety of symptoms, preferentially in early childhood. We report here the nearly complete genome sequence of a novel HPeV type, consisting of 7,062 nucleotides and encoding 2,179 amino acids. M36/CI/2014 was taxonomically classified as HPeV-17 by the picornavirus study group.