Human adenovirus type 7 outbreak in police training center, Malaysia, 2011.Human adenoviruses (HAdVs) consist of nonenveloped, double-stranded DNA DNA: see nucleic acid.
or deoxyribonucleic acid
One of two types of nucleic acid (the other is RNA); a complex organic compound found in all living cells and many viruses. It is the chemical substance of genes. and belong to the family Adenoviridae, genus Mastadenovirus. The 51 recognized serotypes of human adenoviruses have been placed in 7 human adenovirus adenovirus
Any of a group of spheroidal viruses, made up of DNA wrapped in a protein coat, that cause sore throat and fever in humans, hepatitis in dogs, and several diseases in fowl, mice, cattle, pigs, and monkeys. species, A-G (1). These viruses cause infections ranging from mild syndromes to severe, life-threatening disease.
Depending on the species, these viruses may infect respiratory, conjunctival con·junc·ti·val
Relating to the conjunctiva.
pertaining to or emanating from conjunctiva.
congenital conjunctival membrane , gastrointestinal, and genitourinary genitourinary /gen·i·to·uri·nary/ (jen?i-to-u´ri-nar-e) pertaining to the genital and urinary organs.
adj. Abbr. sites. They have been recognized for decades as the primary causes of acute respiratory disease (ARD), gastrointestinal infection, and fever (2). Outbreaks of adenoviruses associated with respiratory disease have been reported worldwide (3,4) and commonly occur among the military trainees (5,6). These cases of ARD are most frequently associated with a strain of HAdV-B, HAdV-7 (7).
We describe the emergence of HAdV-7 in Malaysia. The outbreak occurred during March-April 2011 and involved new police recruits in the Kuala Lumpur Police Training Centre. Approximately 100 trainees were admitted to the Kuala Lumpur Hospital, and 4 more were treated in the intensive care unit. This outbreak affected 851 police trainees and claimed 3 lives.
In April 2011, the virology unit at the Institute for Medical Research, Kuala Lumpur, received respiratory samples from police trainees admitted to Kuala Lumpur Hospital with ARD and tissue samples from 2 of the 3 patients with fatal cases. The postmortem specimens consisted of cerebrospinal, pericardial effusion, and pleural effusion fluids; lung, liver, spleen, and kidney tissues; skin; and bone marrow aspirate as·pi·rate
To take in or remove by aspiration.
A substance removed by aspiration.
The removal by suction of a fluid from a body cavity using a needle. .
Viral nucleic acid was extracted from the clinical samples by using Roche High Pure Viral Nucleic Acid Kit (Roche Applied Science, Mannheim, Germany). Of the initial samples, 10 were screened for respiratory syncytial syncytial /syn·cy·tial/ (sin-sish´al) of or pertaining to a syncytium.
pertaining to or producing a syncytium.
bovine syncytial virus
see retroviridae. viruses, influenza viruses, parainfluenza parainfluenza Infectious disease A virus that causes URIs–up to 50% of croup and 10–15% of bronchiolitis, bronchitis, pneumonias in toddlers Clinical Rhinorrhea, cold-like Sx Risk factors Preschool children; by school age most children have been exposed viruses, human metapneumoviruses, coxsackieviruses, echoviruses, rhinoviruses, coronaviruses, adenoviruses, and bocavirus by multiplex PCR PCR polymerase chain reaction.
polymerase chain reaction
Polymerase chain reaction (PCR) . All samples were then subjected to adenovirus nucleic acid detection by PCR.
Partial HAdV hexon gene was amplified by PCR (8). The SeqMan and Megalign software modules in the Lasergene suite of programs (DNASTAR, Madison, WI, USA) were used to format the nucleotide sequences. A phylogenetic tree was constructed by using the neighbor-joining method from the MEGA4 software (www. megasoftware.net).
A total of 33 clinical specimens, including respiratory and fecal samples as well as postmortem samples, from 21 trainees admitted to Kuala Lumpur Hospital were collected. Of these, only 31 samples from 19 trainees were sufficient for analysis. PCR or reverse transcription PCR was performed on 10 of the 31 samples by using primer sets specific for respiratory viruses with the ResPlex II Panel (QIAGEN, Valencia, CA, USA). The 10 samples contained HAdV-B species.
On the basis of this finding, partial hexon genes of adenovirus were amplified from all 31 samples by using PCR with HAdV-specific primers (8). The results (Table) indicated that 53% (10/19) of the samples tested were positive for adenovirus. An antemortem antemortem /an·te·mor·tem/ (an?te-mor´tem) [L.] occurring before death.
performed or occurring before death. tracheal aspirate sample, received from the first case-patient who died, was positive for adenovirus. Subsequently, postmortem lung and spleen tissue samples tested by PCR were also positive for adenovirus. In the second fatal case, adenovirus was detected from postmortem samples consisting of pleural effusion fluid, pericardial effusion fluid, lung tissue, and serum, but other tissues, such as heart, spleen, and liver, and cerebrospinal fluid were negative (Figure 1).
All positive samples were sequenced, and BLAST sequencing analysis (http://blast.ncbi.nlm.nih.gov/Blast. cgi) showed that their sequences were similar to human adenovirus type 7 strain 0901H2/Shix/CHN/2009 isolated in People's Republic of China in 2009 (9). The phylogenetic tree, constructed on the basis of partial hexon gene (160) nucleotides (Figure 2), revealed that all positive samples by PCR belong to the species Human adenovirus B and are in the same cluster with adenovirus 7.
The outbreak of ARD, caused by HAdV-7, in the Kuala Lumpur Police Training Centre started in early March 2011. The police trainees had signs and symptoms of ARD such as fever, cough, and loss of appetite loss of appetite Medtalk Anorexia, see there . The disease rapidly spread among the trainees, and community-acquired pneumonia was the initial diagnosis early in the outbreak. Other etiologic agents that recently caused ARD, including seasonal influenza virus and pandemic (H1N1) 2009 virus, were excluded because the reverse transcription PCR for influenza viruses was negative.
The source of the infection is not known. There is a strong possibility that one of the trainees was infected with HAdV-7 in the community outside the training center and then spread the infection to others once training resumed. Transmission occurs through respiratory droplets and close contact, which leads to rapid and widespread dissemination. Similar events have been seen in military camps (4), high schools, and day care centers (10). All affected trainees were 20-26 years old. Risk factors such as overcrowding, increased physical activities, and psychological stress could possibly increase susceptibility to ARD. These risk factors associated with outbreaks of HAdV-caused ARD, which are prevalent in military and police training centers, have been reported in previous HAdV outbreaks in military recruits (11).
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In Malaysia, 2 researchers (12,13) described the role of HAdV in causing ARD (12). They analyzed 27 HAdV isolates from patients with ARD who sought consultation and treatment at University of Malaysia Medical Center during 1999-2005. Among the 27 isolates, the following species were represented: 19 (70%) belonged to HAdV-C, 6 (22%) belonged to HAdV-B, and 2 (7%) belonged to HAdV-F. Among the HAdV-B species isolates, 5 had the HAdV-3 serotype and only 1 had the HAdV-7 serotype. An earlier analysis of HAdV isolates in Malaysia (13) revealed that HAdV-21 was associated with acute flaccid paralysis during the outbreak of hand, foot, and mouth disease in Sarawak, but none of the isolates were HAdV-7.
Pneumonia caused by HAdV-7, commonly associated with lower respiratory tract infection While often used as a synonym for pneumonia, the rubric of lower respiratory tract infection can also be applied to other types of infection including lung abscess, acute bronchitis, and emphysema. , can lead to severe disease and death in some infants and immunocompromised immunocompromised /im·mu·no·com·pro·mised/ (-kom´pro-mizd) having the immune response attenuated by administration of immunosuppressive drugs, by irradiation, by malnutrition, or by certain disease processes (e.g., cancer). persons (9,14). Outbreaks of pneumonia caused by HAdV 7 have been reported among hospitalized children in South Korea and in the United States (15). This outbreak demonstrated the potential of ARD caused by HAdV-7 to produce illness and death in police and army recruit camps and in institutional settings. HAdV-7 infection also is fatal in children.
We thank the Director General of Health and the Director of the Institute for Medical Research for permission to publish this article. We also thank the staff of the virology unit in the Institute for Medical Research and laboratory staff of Hospital Kuala Lumpur for sending the specimens.
This research project was funded under the virology operational budget 2011.
Dr Apandi Yusof is a virologist at the Institute for Medical Research, Kuala Lumpur, Malaysia. His primary research interests are epidemiology, surveillance, and outbreak investigation.
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Author affiliation: Institute for Medical Research, Kuala Lumpur, Malaysia
Address for correspondence: Mohd Apandi Yusof, Virology Unit, Infectious Disease Research Centre, Institute for Medical Research, Jalan Pahang, 50588 Kuala Lumpur, Malaysia; email: email@example.com
Table. Patient information and adenovirus PCR results on samples from police trainees with acute respiratory disease from Kuala Lumpur, Malaysia, 2011 * Age, Patient y([dagger]) Sample type RP301/11 ([double dagger]) 22 T/A RP302/11 ([double dagger]) 25 T/A, antemortem Lung, spleen Kidney, liver, skin CSF, BMA RP303/11 21 T/S RP304/11 23 T/S RP305/11 22 T/S RP306/11 22 T/S RP307/11 23 T/S RP308/11 22 T/S RP309/11 26 T/S RP310/11 24 T/S RP311/11 24 T/S RP312/11 22 T/S RP313/11 23 T/S RP314/11 26 Feces RP315/11 20 Feces RP316/11 25 Feces RP317/11 23 R/S RP318/11 22 R/S RP319/11 23 Feces RP320/11 20 Feces RP381/11J 25 Lung, PF, PE, serum CSF, heart, spleen Liver PCR Patient results RP301/11 ([double dagger]) Pos RP302/11 ([double dagger]) Pos Pos Neg Neg RP303/11 Pos RP304/11 Pos RP305/11 Pos RP306/11 Neg RP307/11 Neg RP308/11 Neg RP309/11 Neg RP310/11 Pos RP311/11 Pos RP312/11 Pos RP313/11 Neg RP314/11 Neg RP315/11 Neg RP316/11 Neg RP317/11 Neg RP318/11 Pos RP319/11 ND RP320/11 ND RP381/11J Pos Neg Neg * T/A, tracheal aspirate; pos, positive; neg, negative; CSF, cerebrospinal fluid; BMA, bone marrow aspirate; T/S, throat swab; R/ S, rectal swab; ND, test not done; PF, pericardial fluid; PE, pleural effusion. ([dagger]) All patients were male. ([double dagger]) Fatal case.