Respiratory Virus Panel, When to consider?

Transcription

1 Respiratory Virus Panel, When to consider? Prof. Dr Sandeep Wasankar FRACP ( Australia & Nz ), FERS (Europe), Fellowship in Pediatric Respiratory Medicine, Asthma & Allergy (Australia & Nz), Fellowship in Pediatric Sleep Disorder Medicine (Australia & Nz), Fellowship in Pediatric Infectious Diseases & Vaccinology (Australia & Nz), MD (Peds), DCH, MBBS International Faculty & Senior Consultant Respiratory Medicine, Asthma & Allergy Specialist, Sleep Disorder Medicine Specialist, Infectious Diseases Specialist

2 Prof. Dr Sandeep Wasankar FRACP ( Australia & Nz ), Fellowship in Peds Respiratory Medicine, Asthma & Allergy (Australia & Nz), Fellowship in Peds Sleep Disorder Medicine (Australia & Nz), Fellowship in Peds Infectious Diseases & Vaccinology (Australia & Nz), MD (Peds), DCH, MBBS International Faculty & Senior Consultant Respiratory Medicine, Asthma & Allergy Specialist & Sleep Disorder Medicine Specialist Infectious Diseases & Vaccinology Specialist Hon. Professor, University of Sydney, Australia 15 years of International Experience from the reputed International Children s Hospitals of Australia, NewZealand & Canada Total 24 years of Experience Publications : Many International & National Publications. Author of many Book Chapters. Research : 6 Research Projects Affiliations : Australian & Nz Thoracic Society, Europian Respiratory Society-ERS, World Allergy Organization WAO, AAAAI & American Society of Pediatric Pulmonology - ASPP

3 K I S S S Keep it Simple Short Sweet

4 Respiratory Viral Infections Whats the Viral ARI burden in India? Whats Burden & incidence in our Geographical area in Peds & adults? If in case data is available then which type of tests were performed? Impact on Quality of Life?

5 Viral ARI - Burden in India ARIs are important cause of mortality and morbidity in children under five in India. Methods : This observational study was conducted over two-year period in a tertiary care teaching hospital of Eastern India. Nasal and throat swabs were processed for detection of viruses using mono/multiplex RT polymerase chain reaction. Results: A total of 300 children aged 2 60 months with ARIs were included. The most common age group affected with LRTI was 2 12 mo & with URTI was >12 60 mo. Viruses were detected in 248 cases. In URTI, 77 were positive for single virus and 19 were positive for more than one virus

6 Viral ARI - Burden in India In LRTI, 113 were positive for single virus and 12 were positive for more than one virus. The most common viruses isolated from URTI cases were rhinovirus and adenovirus. The most common viruses isolated from LRTI cases were respiratory syncytial virus and influenza virus Most cases occurred in the months of January, December, and August. Conclusion. Viruses constitute a significant cause of ARI in children under five. RSV, ADV, RV, and IFV were the most prevalent viruses isolated International Journal of Pediatrics, Volume 2016, Article ID , 8 pages, Oct 2016 Viral Agents Causing Acute Respiratory Infections in Children under Five: A Study from Eastern India, Pravakar Mishra, Lipika Nayak

7 Viral ARI - Burden in India Objectives: The aim is to identify the etiology of community acquired pneumonia in children with special reference to atypical bacteria and viruses. Materials and Methods: A total of 94 pneumonia children were enrolled in the study. Sixty-seven did not have an etiological diagnosis by conventional culture. These children were subjected to IF assay by Pneumoslide IgM Results: Ninety-four children were evaluated for etiology by conventional culture. Twentyseven of them had the bacteriological diagnosis. Rest 67 were further analyzed for causative organism using Pneumoslide immunofluorescence test. Among this group, 38 (56.7%) had etiological diagnosis. Atypical bacteria were identified in 23 cases, most common being Mycoplasma pneumoniae and which was more common between 5 months and 2 years of age Viruses were identified in 19 cases, and the most common virus was Respiratory syncytial virus. Mixed pathogens were identified in five children., M. pneumoniae was the common offending agent Conclusions: Atypical bacteria and viruses play an important role as etiological agents in pneumonia in children. Pneumoslide IgM is useful for rapid detection of atypical bacteria and viruses Kumar K J, Ashok Chowdary K V, Usha H C, Kulkarni M, Manjunath V G. Etiology of community acquired pneumonia among children in India with special reference to atypical pathogens. Lung India 2018;35:116-20

8 Acute respiratory tract infections are the largest cause of morbidity and mortality among underfive children worldwide. In India, pneumonia is the single most important cause of death below 5 yrs, causing 27.5% of the Mortality under 5 yrs. In India, there are only a few systematic review or studies regarding the etiology of pneumonia in children.in general, the etiology can be identified in only 30% 50% of cases using conventional methods. This lack of information leads to inappropriate use of antibiotics with consequent antibiotic resistance and increased cost. In CAP, it is not possible to clinically or radiologically to distinguish between the etiological agents [ & hence, serological diagnosis would be very helpful. IgM antibodies which appears after infection are more valuable for the early diagnosis in children. IFAs detected the IgM antibodies against nine pathogens has reasonable sensitivity and specificity. The aim of this study is to find the etiology of CAP in children with special reference to atypical bacteria and viruses by utilizing Pneumoslide-M test -IFAs

9 Viral ARI - Burden in India Overall, approximately 46,000 children were screened and over 4000 enrolled, making it one of the world s largest single- centre studies on pneumonia etiology. Corresponding PCR of BAL yielded organisms in 93% samples; however a single organism (bacteria or virus) was found in only 33%. The rest had multiple organisms in different combinations. Multiplex PCR of nasopharyngeal aspirate samples yielded multiple bacteria and viruses. Only 1.4% children did not show any of the 25 species looked for. The majority (59%) had multiple organisms, making it impossible to attribute causality Surprisingly, cytomegalovirus (CMV) was the dominant isolate among viruses, followed by RSV, followed by Rhinovirus, Coronavirus, Parainfluenza virus, Influenza virus, etc. Community Acquired Pneumonia Etiology Study (CAPES) was initiated at PGIMER Chandigarh in 2010, in collaboration with Karolinska Institute, Stolkholm

10 Viruses are an important cause of ALRIs in Chinese children constituting 1/3 of total cases. RSV is the most common pathogen.

11 Respiratory Viruses Influenza A and Influenza B Influenza A seasonal subtypes (H3N2, H1N1) Avian influenza ( H5N1, H5N2, H7N9) influenza A (H7N9) virus in China (2013) RSV - Respiratory Syncytial Virus, subtype -A & B PIV - Parainfluenza 1, 2, 3 hmpv - Human Metapneumovirus Rhinovirus Adenovirus Human Bocavirus (2005) Human Coronavirus NL63 or HKU1 Severe Acute Respiratory Syndrome-Coronavirus (SARS-CoV), 2003 China-Asia Middle East Respiratory Syndrome -Coronavirus (MERS- CoV) CMV & EBV

12 Approach Which is best test need to be Developed & performed? Are they available? Are they Treatable?

13 How do I identify Viruses? - Multiplex-PCR Multiplex polymerase chain reaction refers to the use of polymerase chain reaction to amplify several different DNA sequences simultaneously (as if performing many separate PCR reactions all together in one reaction) This process amplifies DNA in samples using multiple primers and a temperature-mediated DNA polymerase in a thermal cycler

14 How do I identify? - Multiplex-PCR Sensitivity 97 %, Specificity 100% Sample : NP aspirates, NS, Nasal Wash, BAL 20 Respi Viruses Time : 1 hour Advantage: less tech expertise Cost effective

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16 RT- PCR A real-time polymerase chain reaction (Real-Time PCR), also known as quantitative polymerase chain reaction (qpcr), is a laboratory technique of molecular biology based on the polymerase chain reaction (PCR). It monitors the amplification of a targeted DNA molecule during the PCR, i.e. in real-time, and not at its end, as in conventional PCR. Real-time PCR can be used quantitatively (quantitative real-time PCR), and semi-quantitatively, i.e. above/below a certain amount of DNA molecules (semi quantitative real-time PCR). Two common methods for the detection of PCR products in real-time PCR are: (1) non-specific fluorescent dyes that intercalate with any doublestranded DNA, and (2) sequence-specific DNA probes consisting of oligonucleotides that are labelled with a fluorescent reporter which permits detection only after hybridization of the probe with its complementary sequence.

17 PLOS ONE DOI: /journal.pone February 24, / 11 Usefulness of multiplex PCR methods and respiratory viruses distribution in children below 15 years old according to age, seasons and clinical units in France: A 3 years retrospective study Benoit Visseaux1*, Gilles Collin1

18 Detection of viral respiratory pathogens in mild and severe acute respiratory infections in Singapore Lili Jiang, Vernon Jian Ming, Sci Rep. 2017; 7: The performance of various technologies and case definitions for viral respiratory pathogens presenting with ARI differs substantially between community and hospital-based settings. PCR-based assays may still be relevant for detecting influenza amongst inpatients that present late but less so for community ARI episodes with delayed presentations. The PathChip may add value for respiratory virus detection in samples negative by multiplex RT- PCR, but only for community-ari. Finally,CDC and WHO ILI case definitions had similar performance for mild ARI, but performed less adequately amongst presentations severe enough to require hospitalisation, including in older individuals. Rational strategies for diagnosis and surveillance of influenza and other respiratory viruses must acknowledge the differences between these two populations.

19 Impact of Early Detection of Respiratory Viruses by Multiplex PCR Assay on Clinical Outcomes in Adult Patients Urania Rappo, Audrey N. JCM , 2016 In conclusion, the use of a sensitive, rapid, multiplex PCR to diagnose influenza in adults was associated with decreased admission rates, shorter lengths of stay, shorter durations of antimicrobial therapy, and fewer chest radiographs than the use of conventional methods.

20 How do we identify in OPD & IPD pts?? Develop your own panel : Which is quicker & easy Detects max viruses Less tech expertise Cost effective

21 Quidel QuickVue Influenza A/B POC Tests Specificity : 100%, Sensitivity : 23%, as compared to RT-PCR

22 Quidel QuickVue Influenza A/B Tests

23 Quidel QuickVue Influenza A/B Tests

24 When to consider Viral panel? If max family members affected Outbreak in Preschools & Schools Outbreak in Community Outbreak in defined Geo area Visitor from other part of country & other country High Risk Kids - Chronic Lung Disease & others

25 When to consider Viral Panel? - High Risk Chronic organ dysfunction Organ Transplants Oncology Pts on Immuno-Supp drugs Long term Steroids & Immuno-Supp drugs Heart Failure Lt to Rt shunts, cardiomyopathy CF, PCD Immune - Deficiency often SCID CPAM, Sequestration, Congential Lobar Emhysema ILD

26 Take home Key message Identify Viruses in your area Choose & Develop with better Sensitivity & Specificity- Multiple-PCR Covers Max Viruses& Quicker & Easy - Multiplex- PCR Quidels Tests for OPD & IPD Pts Save money on : Antibiotics, Beds & health care & multiple presentations to ED Work losses & School losses

27 Treatment-DOC Virus Treatment Prevention Influenza virus Oseltamivir Peramivir Zanamivir Influenza vaccine [73] Chemoprophylaxis with: Zanamivir Oseltamivir Respiratory syncytial virus Ribavirin RSV immunoglobulin Palivizumab Parainfluenza virus Ribavirin Herpes simplex virus Acyclovir Varicella-zoster virus Acyclovir Varicella-zoster immunoglobulin Adenovirus Ribavirin Measles virus Ribavirin Intravenous immunoglobulin Cytomegalovirus Ganciclovir Foscarnet Intravenous immunoglobulin

28 Thank you all Prof. Dr Sandeep Wasankar FRACP ( Australia & Nz ), Fellowship in Peds Respiratory Medicine, Asthma & Allergy (Australia & Nz), Fellowship in Peds Sleep Disorder Medicine (Australia & Nz), Fellowship in Peds Infectious Diseases & Vaccinology (Australia & Nz), MD (Peds), DCH, MBBS International Faculty & Senior Consultant Respiratory Medicine, Asthma & Allergy Specialist & Sleep Disorder Medicine Specialist Infectious Diseases & Vaccinology Specialist Hon. Professor, University of Sydney, Australia 15 years of International Experience from the reputed International Children s Hospitals of Australia, NewZealand & Canada Total 24 years of Experience Publications : Many International & National Publications. Author of many Book Chapters. Research : 6 Research Projects Affiliations : Australian & Nz Thoracic Society, Europian Respiratory Society-ERS, World Allergy Organization WAO, AAAAI & American Society of Pediatric Pulmonology - ASPP

29 Common respiratory viral infections, such as RSV, PIV, and influenza, cause a spectrum of illnesses that range from nuisance "colds and flus" to more serious lower respiratory tract disease Increased awareness of the impact that respiratory viral infections can have on an individual patient, the healthcare system, and society as a whole have rendered the phrase "it's just a viral infection" something of a relic

30 Diagnostic Value of Nasopharyngeal Aspirates in Children with Lower Respiratory Tract Infections Chin Med J (Engl) Mar 20; 130(6): Results: We collected paired specimens from 488 children. The positive rate of pathogen was 61.6%. For Streptococcus pneumoniae, NPA culture had the specificity of 89.9% and negative predictive value of 100% in age 3 years, the specificity of 97.2% and negative predictive value of 98.9% in age >3 years. For Mp, the positive predictive values of NPA was 77.4% in children 3 years, and 89.1% in children >3 years. For PIV III, NPA specimen had the specificity of 99.8% and negative predictive value of 96.5% in children 3 years. For adenovirus, NPA had the specificity of 97.8% and negative predictive value of 98.4% in age 3 years, the specificity of 98.9% and negative predictive value of 99.3% in age >3 years. Conclusions: NPAs are less invasive diagnostic respiratory specimens, a negative NPA result is helpful in rule out lower airway infection; however, a positive result does not reliably rule in the presence of pathogens.

31 Comparative Study of Nasopharyngeal Aspirate and Nasal Swab Specimens for Diagnosis of Acute Viral Respiratory Infection Rita Y. T. Sung,. Journal of Clinical Micro , ASM Paired nasopharyngeal aspirate (NPA) and nasal swab (NS) samples from 475 children hospitalized for acute respiratory infection were studied for the detection of Influenza virus, Parainfluenza virus, respiratory syncytial virus, and adenovirus by immunofluorescence test, viral culture, and multiplex PCR assay The overall sensitivity of viral detection with NPA specimens was higher than that obtained with NS specimens.

32 4 weeks to 6 mths : Respiratory Syncitial Virus (RSV) Prainfluenza Virus(PIV) Nasopharyngeal (NP) swab for PCR or immunofluorescence, viral culture and direct fluorescent antibody (DFA) staining, acute and convalescent serology. Whereas influenza and RSV have winter-spring seasonality, PIV is present year-round

33 6 mths to 5 yrs :RSV,PIV, influenza,adenovirus, rhinovirus NP swab for- IF, PCR, viral culture and DFA staining, acute and convalescent serology

34 Viruses: varicella zoster virus, coronaviruses, enteroviruses (coxsackievirus and echovirus), cytomegalovirus, Epstein-Barr virus, mumps virus, herpes simplex virus (in newborns), measles virus, Varicella zoster virus: clinically by history and examination; quadrupling of acute and convalescent serology, IF assay of skin secretions; cytomegalovirus, Epstein- Barr virus: quadrupling of acute and convalescent serology, IgM antibody in acute serum; measles virus: quadrupling of acute and convalescent serology, IF assay of NP secretions

35 PERCH enrolled 4232 casesand 5325 controls from nine sites in seven developing countries. The controls included healthy children as well as those with respiratory symptoms not fulfilling the definition of pneumonia. Quantitative estimation of viral load in nasopharyngeal /oropharyngeal samples showed considerable overlap between radiographically confirmed cases and controls. Children with very severe pneumonia and those who died did not have higher viral loads. These findings suggest that quantitative PCR for viruses may not be discriminatory Almost 90% cases and 80% controls had at least one of the 17 viruses tested for by multiplex PCR in nasopharyngeal/oropharyngeal samples; the respective proportions for 2 viruses were 53% and 40%; and for >3 viruses were 18% and 12%.

36 Community Acquired Pneumonia Etiology Study (CAPES) was initiated at PGIMER Chandigarh in 2010, in collaboration with Karolinska Institute,Stolkholm Overall, approximately 46,000 children were screened and over 4000 enrolled, making it one of the world s largest single- centre studies on pneumonia etiology. Corresponding PCR of BAL yielded organisms in 93% samples; however a single organism (bacteria or virus) was found in only 33%. The rest had multiple organisms in different combinations. Multiplex PCR of nasopharyngeal aspirate samples yielded multiple bacteria and viruses. Only 1.4% children did not show any of the 25 species looked for. The majority (59%) had multiple organisms, making it impossible to attribute causality. Surprisingly, cytomegalovirus (CMV) was the dominant isolate among viruses, followed by RSV, followed by Rhinovirus, Coronavirus, Parainfluenza virus, Influenza virus, etc.

37 Laryngeal Papillomatosis PCR on biopsied tissue

38