Parainfluenza Virus Infection Research Articles

Pre-emptive oral ribavirin therapy of paramyxovirus infections after haematopoietic stem cell transplantation: a pilot study.

Infections with the paramyxoviruses, respiratory syncytial virus (RSV) and parainfluenza virus (PIV) can result in serious morbidity and mortality after haemopoietic stem cell transplant (HSCT). Once pneumonia develops, the outcome of these infections is often poor despite anti-viral therapy. Aerosolised ribavirin has been evaluated as pre-emptive therapy for post-transplant RSV infections with some success. Due to the financial and logistic burden involved with the use of aerosolised ribavirin, we explored the efficacy and toxicity of oral ribavirin for pre-emptive therapy of post-transplant RSV and PIV infections in a dose escalating schedule (15-60 mg/kg/day). Five episodes each of RSV and PIV were treated in seven patients. Five patients were receiving treatment for GVHD and two acquired the infection in the pre-engraftment period. All the episodes of RSV infection improved with oral ribavirin with dose escalation to 30-45 mg/kg in three of them. On the other hand, only two of the five PIV infections improved with oral ribavirin. Of the three non-responders, two infections were acquired in the pre-engraftment period with one death from PIV pneumonia. Reversible anaemia was the only side-effect noted in patients treated for over 2 weeks. Thus, the use of oral ribavirin was well tolerated in the post-transplant period with no untoward toxicities. There was a trend towards better response in RSV infections, which needs to be further explored in controlled studies.

Community respiratory virus infections following lung transplantation.

Respiratory infections remain a significant cause of morbidity and mortality after lung transplantation. In addition to cytomegalovirus, the community respiratory viruses such as respiratory syncytial virus (RSV), parainfluenza virus (PIV), influenza virus, and adenovirus, are important causes of infection in transplant recipients, often involve the lower respiratory tract, and may be associated with significant morbidity and mortality. In this review, we summarize the current state of knowledge regarding the epidemiology, clinical manifestations, diagnosis, treatment and outcomes associated with RSV, PIV, influenza virus, and adenovirus infections in lung transplant recipients.

Parainfluenza virus infections after hematopoietic stem cell transplantation: risk factors, response to antiviral therapy, and effect on transplant outcome

AbstractParainfluenza virus (PIV) infections may be significant causes of morbidity and mortality in patients undergoing stem cell transplantation, but data regarding their impact on transplant-related mortality is limited. This study sought to determine the risk factors of PIV acquisition and progression to lower respiratory tract infection, their impact on transplant-related mortality, and the effectiveness of antiviral therapy. A total of 3577 recipients of hematopoietic stem cell transplantation (HSCT) between 1990 and 1999 were studied. PIV infections occurred in 253 patients (7.1%); 78% of these infections were community acquired. Multivariable analysis identified the receipt of an unrelated transplant as the only risk factor for PIV acquisition; the dose of corticosteroids at the time of PIV infection acquisition was the primary factor associated with the development of PIV-3 pneumonia, both among allogeneic and autologous HSCT recipients. Both PIV-3 upper respiratory infection and pneumonia were associated with overall mortality. Pulmonary copathogens were isolated from 29 patients (53%) with pneumonia. Mortality was highly influenced by the presence of copathogens and the need for mechanical ventilation. Aerosolized ribavirin with or without intravenous immunoglobulin did not appear to alter mortality from PIV-3 pneumonia, nor did such therapy decrease the duration of viral shedding from the nasopharynx among patients with pneumonia. Corticosteroid administration thus drives the development of PIV pneumonia in a dose-dependent fashion, even among autologous HSCT recipients. Both upper and lower tract PIV infections are predictors of mortality after HSCT. Currently available antiviral therapy appears to be inadequate in reducing viral shedding or mortality once pneumonia is established.

Receptor specificities of human respiroviruses.

Through their hemagglutinin-neuraminidase glycoprotein, parainfluenza viruses bind to sialic acid-containing glycoconjugates to initiate infection. Although the virus-receptor interaction is a key factor of infection, the exact nature of the receptors that human parainfluenza viruses recognize has not been determined. We evaluated the abilities of human parainfluenza virus types 1 (hPIV-1) and 3 (hPIV-3) to bind to different types of gangliosides. Both hPIV-1 and hPIV-3 preferentially bound to neolacto-series gangliosides containing a terminal N-acetylneuraminic acid (NeuAc) linked to N-acetyllactosamine (Galbeta1-4GlcNAc) by the alpha2-3 linkage (NeuAcalpha2-3Galbeta1-4GlcNAc). Unlike hPIV-1, hPIV-3 bound to gangliosides with a terminal NeuAc linked to Galbeta1-4GlcNAc through an alpha2-6 linkage (NeuAcalpha2-6Galbeta1-4GlcNAc) or to gangliosides with a different sialic acid, N-glycolylneuraminic acid (NeuGc), linked to Galbeta1-4GlcNAc (NeuGcalpha2-3Galbeta1-4GlcNAc). These results indicate that the molecular species of glycoconjugate that hPIV-1 recognizes are more limited than those recognized by hPIV-3. Further analysis using purified gangliosides revealed that the oligosaccharide core structure is also an important element for binding. Gangliosides that contain branched N-acetyllactosaminoglycans in their core structure showed higher avidity than those without them. Agglutination of human, cow, and guinea pig erythrocytes but not equine erythrocytes by hPIV-1 and hPIV-3 correlated well with the presence or the absence of sialic acid-linked branched N-acetyllactosaminoglycans on the cell surface. Finally, NeuAcalpha2-3I, which bound to both viruses, inhibited virus infection of Lewis lung carcinoma-monkey kidney cells in a dose-dependent manner. We conclude that hPIV-1 and hPIV-3 preferentially recognize oligosaccharides containing branched N-acetyllactosaminoglycans with terminal NeuAcalpha2-3Gal as receptors and that hPIV-3 also recognizes NeuAcalpha2-6Gal- or NeuGcalpha2-3Gal-containing receptors. These findings provide important information that can be used to develop inhibitors that prevent human parainfluenza virus infection.

Parainfluenza virus 3 infection after stem cell transplant: relevance to outcome of rapid diagnosis and ribavirin treatment.

All 456 recipients of hemopoietic stem cell transplants (SCT) at the Hammersmith Hospital, London, from January 1990 through September 1996 were reviewed for parainfluenza virus (PIV) infections. Of the 24 (5.3%) PIV type 3 (PIV3)-infected patients, 10 had upper respiratory tract infection and all survived, but 8 of 14 with pneumonia died. A same-day immunofluorescence test diagnosed PIV3 infection in 20 (83%) of the 24 cases, but virus culture diagnosed only 10 (42%) of the 24 cases after a mean delay of 12 days. Eighteen PIV3-infected patients first received ribavirin at a median of 3 days after onset of symptoms, but, nevertheless, 2 patients shed PIV3 for 4 months. Six of 10 patients with pneumonia died despite early ribavirin therapy. The cause of death was not established by autopsy; 3 patients had concurrent infections, but in 3, only PIV3 was detected. The value of immunofluorescence testing for early diagnosis and treatment of PIV3 infection after SCT is demonstrated, but the outcome was not altered.

Parainfluenza virus type 3 infections in hematopoetic stem cell transplant recipients: response to ribavirin therapy.

Parainfluenza virus (PIV) infection can be a problem among hematopoetic stem cell transplant recipients. 125 patients were prospectively evaluated for respiratory viral infections. We describe 5 patients with PIV 3 infection and their response to early treatment with ribavirin.

Rapid detection of respiratory viruses by centrifugation enhanced cultures from children with acute lower respiratory tract infections.

Acute respiratory tract infection (ARI) is the major cause of morbidity and mortality in young children in developing countries. Information on viral aetiology in ARI in India is very limited. The aim of the study was to define the role of viruses in acute lower respiratory tract infections (ALRTI) in children in India using centrifugation enhanced cultures followed by indirect immunofluorescence (IIF). Nasopharyngeal aspirates (NPAs) were collected from children from September 1995 to April 1997, attending paediatric clinic of All India Institute of Medical Sciences (AIIMS) with symptoms of ALRTI. Virus isolation was done by centrifugation enhanced cultures using HEp-2, LLC-MK2 and MDCK cells. The viruses were identified at 24-48 h post inoculation by IIF staining using monoclonal antibodies to respiratory syncytial virus (RSV), parainfluenza virus (PIV), influenza virus and adenovirus. Of 200 NPA samples, 89 (44.5%) were positive for one or more viral pathogens. RSV was detected in 34 (17%) of all ALRTI cases followed by influenza viruses in 29 (14.5%), PIVs in 23 (11.5%) and adenoviruses in three (1.5%). In 79 children with bronchiolitis, RSV was most frequently isolated (25%) pathogen, while in bronchopneumonia cases (101) the most common viral pathogen was influenza virus (17%). In eight cases (4%) of ALRTI dual infections were detected. In 100 NPA specimens IIF staining on direct cell smears was carried out and viruses were detected in only 17%. RSV and influenza virus infection peaked from September to December, where as PIV infections were more frequent from January to April. Respiratory viruses accounted for 44.5% of cases of ALRTI in India and the results of viral aetiology could be given in 24-48 h using centrifugation enhanced cultures. RSV was the most common viral agent associated with ALRTI in children under 5 years of age with greater association with bronchiolitis.

Impact of respiratory virus infections on persons with chronic underlying conditions.

While hospitalization rates have declined overall, hospitalizations for acute lower respiratory tract infections have increased steadily since 1980. Development of new approaches for prevention of acute respiratory tract conditions requires studies of the etiologies of infections and quantification of the risk of hospitalization for vulnerable patients. To determine the frequency of specific virus infections associated with acute respiratory tract conditions leading to hospitalization of chronically ill patients. Analysis of viral etiology of patients hospitalized with acute respiratory tract conditions between July 1991 and June 1995. Four large clinics and related hospitals serving diverse populations representative of Harris County, Texas. A total of 1029 patients who were hospitalized for pneumonia, tracheobronchitis, bronchiolitis, croup, exacerbations of asthma or chronic obstructive pulmonary disease, and/or congestive heart failure. Virus infection, defined by culture, antigen detection, and significant rise in serum antibodies, by underlying condition; hospitalization rates by low- vs middle-income status. Ninety-three percent of patients older than 5 years had a chronic underlying condition; a chronic pulmonary condition was most common. Patients with chronic pulmonary disease from low-income populations were hospitalized at a rate of 398.6 per 10000, almost 8 times higher than the rate for patients from middle-income groups (52.2 per 10000; P<.001). Of the 403 patients (44.4% of adults and 32.3% of children) who submitted convalescent serum specimens for antibody testing, respiratory tract virus infections were detected in 181 (44.9%). Influenza, parainfluenza, and respiratory syncytial virus (RSV) infections accounted for 75% of all virus infections. Our study suggests that respiratory virus infections commonly trigger serious acute respiratory conditions that result in hospitalization of patients with chronic underlying conditions, highlighting the need for development of effective vaccines for these viruses, especially for parainfluenza and RSV.

Respiratory Syncytial and Other Virus Infections in Persons with Chronic Cardiopulmonary Disease

Respiratory syncytial virus (RSV) has been increasingly recognized as an important cause of serious respiratory illness in some adult populations, including those with underlying cardiopulmonary diseases. However, the precise incidence and the clinical impact of RSV in this group are unknown. Therefore, the incidence and clinical impact of RSV infection in persons with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) who reside in the community were prospectively evaluated over two consecutive winters in 134 persons. Eight RSV (incidence of 4.3 per 100 subject-winters), 13 influenza A (incidence of 7.0 per 100 subject-winters), seven rhinovirus, nine coronavirus, and two parainfluenza virus infections were identified. The clinical illnesses associated with RSV and influenza A virus were similar, causing both upper and lower respiratory signs and symptoms. The clinical impact was significant as three of eight RSV-infected subjects were hospitalized compared with six of 13 influenza A-infected persons and zero of seven rhinovirus-infected persons.

Parainfluenza virus infection among adults hospitalized for lower respiratory tract infection.

To better define the contribution of human parainfluenza viruses (HPIVs) to lower respiratory tract infection in adults, we tested acute- and convalescent-phase serum specimens from hospitalized adults participating in a population-based prospective study of lower respiratory tract infection during 1991-1992. We tested all available specimens from the epidemic seasons for each virus and approximately 300 randomly selected specimens from the corresponding off-seasons for antibodies to HPIV-1, HPIV-2, or HPIV-3. During the respective epidemic season, HPIV-1 infection was detected in 18 (2.5%) of 721 and HPIV-3 infection in 22 (3.1%) of 705 patients with lower respiratory tract infection. Only 2 (0.2%) of 1,057 patients tested positive for HPIV-2 infection. No HPIV-1 infections and only 2 (0.7% of 281 patients tested) HPIV-3 infections were detected during the off-seasons. HPIV-1 and HPIV-3 were among the four most frequently identified infections associated with lower respiratory tract infection during their respective outbreak seasons.

Epidemiological features of parainfluenza virus infections: laboratory surveillance in England and Wales, 1975-1997.

Hospital laboratory reports of parainfluenza virus (PIV) infections from England and Wales between 1975 and 1997 were analysed with regard to PIV type and seasonality, and in addition, those between 1985 1997 with regard to age, sex and clinical features. Laboratory-based surveillance data highlight striking differences in the seasonality of different PIV types. PIV-3 reports demonstrated a clear annual epidemic cycle, with a peak usually occurring in late spring or summer, whereas peaks of PIV-1 and PIV-2 occurred at one or two year intervals, in the late autumn or early winter. PIV-4 also occurred most frequently in the late autumn or early winter, but a clear epidemic cycle could not be identified. Laboratory surveillance data also provide insight into the age and disease distribution of PIV infection in children and indicate severity of PIV infection in immunosuppressed adults. Of 8221 PIV reports received between 1985-1997, PIV-3 accounted for 70.8%, PIV-1 for 17.2%, PIV-2 for 7.5%, and PIV-4 for 1.1%; 64.1% of reports came from infants under one year, 24.4% from children aged 1-4 years and 7.2% from individuals aged 5 years or older, with an excess of males in all age groups. Bronchiolitis, croup and pneumonia occurred in association with all PIV types. In children under 1 year, PIV-2 infections were more likely to be associated with bronchiolitis than infections with other PIV types. In children under 15 years, croup was more frequently associated with PIV-1 and PIV-2 than with PIV-3 or PIV-4. In 392 (7.2%) of the reported PIV infections between 1989 and 1997 an underlying condition was implicated, which included immunosuppression or chronic cardiac or pulmonary disease. Considerable morbidity is associated with PIV infections in infants and young children and would make the widescale use of a vaccine a valuable public health intervention. Surveillance information is essential to guide the development and use of preventive measures as well as to monitor their effectiveness.

パラインフルエンザウイルス２型の抗体価の上昇を伴った器質化肺炎の１例

An adult case of organizing pneumonia with increasing parainfluenza virus antibody titer is reported. A 69-year-old man was admitted to this hospital because of bilateral pulmonary infiltrates involving the upper right and upper left lobes. PAPM and EM were administered intravenously. Sputum cultures yielded a normal respiratory flora. Bronchoscopic examination, including bacteriologic and cytologic examination of bronchoalveolar washings, was negative. Organizing pneumonia demonstrating organization not containing fibrin was diagnosed by transbronchial, lung biopsy (TBLB). Steroid pulse therapy was very effective in this case. The abnormal shadows in the chest X-rays disappeared. The antibody titer against the type 2 parainfluenza virus was increased. It seems that parainfluenza virus infection may cause some organizing pneumonia among adults.

Isolation of highly fusogenic variants of simian virus 5 from persistently infected cells that produce and respond to interferon.

A series of experiments were undertaken to examine how interferon and neutralizing antibodies influence the ability of simian virus 5 (SV5) (strain W3) to establish and maintain persistent infections in murine cells. In contrast to the rapid decline in SV5 protein synthesis observed in murine BALB/c fibroblasts (BF cells), which produce and respond to interferon, between 24 and 48 h postinfection there was no inhibition of virus protein synthesis in MSFI- cells, skin fibroblasts derived from alpha/beta-interferon receptor knockout BALB/c mice. Furthermore, the addition of anti-interferon antibodies to the culture medium of infected BF cells significantly reduced the observed decline in virus protein synthesis. Following infection of untreated BF cells, the majority replicated virus but survived the infection and eventually cleared the virus after 8 to 15 days. However, not all the cells were cured, and the cultures became persistently infected. Upon passage of persistently infected cultures, the virus fluxed between active and repressed states as a consequence of interferon production. This resulted in a balance being reached in which only 5 to 20% of the cells were infected at any one time. After 30 passages of the persistently infected cells, highly fusogenic virus variants arose (one of which was isolated and termed W3-f). W3-f remained as sensitive to interferon as the parental W3 isolate but, in the absence of interferon, spread much more rapidly than the parental W3 strain through BF cell monolayers. Sequence analysis revealed no deduced amino acid differences between the F proteins of W3 and W3-f. BF cell cultures persistently infected with W3-f were rapidly cleared of virus by the addition of virus-neutralizing antibodies to the culture medium. In contrast, neutralizing antibodies had little effect on the numbers of cells persistently infected with W3 over several passages. These results suggest that the ability of paramyxoviruses to cause cell-cell fusion may be selected for in vivo as a consequence of their adaptation to the interferon response rather than their need to escape from neutralizing antibodies. The significance of these observations with regard to persistent parainfluenza virus infections in vivo is further discussed.

Ribavirin therapy in bone marrow transplant recipients with viral respiratory tract infections.

Treatment with ribavirin was instituted in 12 allogeneic and one autologous bone marrow transplant (BMT) recipients with proven respiratory syncytial virus (RSV), influenza B virus or parainfluenza virus infections. RSV was diagnosed in six cases, influenza B virus in four and parainfluenza virus in three patients. Ribavirin was given orally or intravenously (15-20 mg/kg/day in three divided doses) and in nine cases with the addition of ribavirin inhalations (6 g/day). Three patients required ventilator support. Three out of seven patients with pneumonia, including one patient with RSV who developed pulmonary infiltrates 10 days after the start of therapy, died despite treatment with ribavirin (two RSV, one influenza B). Multiple etiological agents were found in the fatal cases. The clinical condition improved in 10 of 13 patients during therapy. No serious adverse effects of systemic ribavirin were noticed. Two patients had reversible signs of hemolysis but only one patients required more erythrocyte transfusions than expected after BMT. Obstructive respiratory distress was often observed (6/9 patients receiving ribavirin inhalation therapy), which resulted in discontinuation of aerosolized therapy in four cases. Time to engraftment (WBC < 0.2 x 10(9)/l) did not differ from other non-treated BMT patients. We conclude that ribavirin is well tolerated both orally and intravenously and it may, if instituted before development of hypoxia, reduce morbidity and mortality of RSV, influenza B and parainfluenza in this group of patients.

Respiratory disease due to parainfluenza virus in adult bone marrow transplant recipients.

We reviewed the frequency and clinical course of parainfluenza virus (PIV) infections in 1,173 adult bone marrow transplant (BMT) recipients cared for at The University of Texas M.D. Anderson Cancer Center (Houston). Between January 1991 and September 1994, PIV was isolated from the respiratory secretions of 61 (5.2%) of these patients. Thirty-four (56%) of the 61 patients had uncomplicated upper respiratory tract illnesses and survived. The remaining 27 patients (44%) developed pneumonia, and the associated mortality was 37% (10 of 27 patients). Twenty-three (85%) of the patients with pneumonia had had preceding upper respiratory illnesses. Of the 10 patients who died, nine died within 100 days after transplantation. Histopathologic examination of lung tissue from seven patients revealed intracytoplasmic viral inclusions in six, a finding consistent with invasive PIV pneumonia, and viral changes in the seventh patient. Seven of the 10 patients who died had other serious concurrent infections. Of 42 patients who developed PIV infection early after transplantation (i.e., < 100 days), the frequency of pneumonia was higher among the 18 allogeneic BMT recipients (61%) than among the 24 autologous BMT recipients (42%), and the associated mortality was also higher (55% vs. 30%, respectively). PIVs are an important cause of life-threatening pneumonia in adult BMT recipients, particularly patients who have recently undergone allogeneic bone marrow transplantation.

Parainfluenza and Influenza Virus Infections in Pediatric Organ Transplant Recipients

We retrospectively reviewed parainfluenza and influenza virus infections that occurred in pediatric organ transplant recipients at our hospital from January 1985 through September of 1992. Cultures of respiratory specimens revealed 45 infections in 42 transplant recipients (32 cases of parainfluenza and 13 cases of influenza virus infection). The following organs were transplanted: liver (28 patients), small bowel with and without liver (4), heart (3), lung with and without heart (5), and kidney (2). Clinical presentations of the patients and outcomes were similar regardless of the type of virus isolated or the type of organ transplanted. There were 20 cases in which patients had upper respiratory symptoms but did not require supplemental oxygen, nine cases in which patients required oxygen supplementation only, and eight cases in which the patients survived with mechanical ventilation. Eight patients died (five had parainfluenza, three had influenza virus infection); four children had serious concurrent infections (cytomegaloviral pneumonia in one patient, bacteremia in two, bacteremia and pneumonia in one). Factors associated with poor outcome for the entire group were age (increased morbidity and mortality if < 6 months old), augmentation of immunosuppression, and onset of infection within 1 month of transplantation. In this patient population, parainfluenza and influenza infections were important causes of morbidity and mortality.

Parainfluenza virus infection in adult bone marrow transplant recipients

The clinical course of parainfluenza virus infection occurring in 8 of 265 (3%) adult bone marrow transplant recipients during 1991 was reviewed. Parainfluenza virus type 3 was isolated from all eight patients. The clinical course ranged from self-limited upper respiratory tract infections (2 patients) to severe lower respiratory tract disease (6 patients) associated with a 50% mortality. This study highlights the important role of community respiratory viruses such as parainfluenza virus in the etiology of pneumonia in immunocompromised adults.

Confessional

Increasing age is associated with the development of CD8⁺ T cell clonal expansions (TCE) that can dominate the peripheral T cell repertoire and interfere with immune responses to infection and vaccination. Some TCE are driven by chronic infections, consistent with dysregulated outgrowth of T cell clones in response to persistent antigenic stimulation. However, a second class of TCE develops with age in the absence of chronic infections and is poorly understood in terms of origin or Ag dependence. In this study, we present evidence that Ag-specific TCE develop at high frequencies from conventional memory CD8⁺ T cell pools elicited by nonpersistent influenza and parainfluenza virus infections. Putative TCE occurred in both the central- and effector-memory CD8⁺ T cell populations and did not require Ag for their maintenance. In addition, they were similar to normal memory T cells in terms of phenotype and function, suggesting that they develop stochastically from the memory T cell pool. These data suggest that memory T cell pools become progressively dysregulated over time and this may have a significant impact on immune responsiveness in the aged.

Role of Moraxella (Branhamella) catarrhalis as a respiratory pathogen in children.

During a 12-month surveillance period in 1981-1982, Moraxella catarrhalis was detected in cultures from nasopharyngeal aspirates from 76 (17%) of 449 children hospitalized with middle or lower respiratory tract infection. Seroconversion to M. catarrhalis was positive in 4 (5%) of the 76 patients with M. catarrhalis present in nasopharyngeal aspirates and in 4 (1%) of 373 patients with a negative finding. Although children with respiratory tract infections were often colonized by the organism, this was rarely the infective agent of the middle or lower airways. Four of 8 patients with seroconversion to M. catarrhalis exhibited a concomitant RSV infection. The carriage of this species was more closely associated with parainfluenza virus infections. Serological responses to M. catarrhalis were not associated with acute otitis media, and were also rare in children with pneumonia. It is concluded that bronchopulmonary infections caused by M. catarrhalis are rare in children, and that M. catarrhalis aetiology need not be considered in the selection of antibiotics in cases of community-acquired pneumonia or other infections of the middle or lower respiratory tract affecting primarily healthy children.

Nutritional Effects on Response of Children in Developing Countries to Respiratory Tract Pathogens: Implications for Vaccine Development

Malnutrition and respiratory disease commonly occur together, and the immunologic defects caused by malnutrition may affect clinical responses and the impact of vaccines. These defects include impaired maturation and function of T lymphocytes, diminished secretory immune responses, poor humoral antibody responses to polysaccharide antigens, deficient complement activity (especially the alternative pathway), and impaired antimicrobial mechanisms by phagocytic cells. In addition, protein-energy malnutrition often leads to very high serum levels of IgE as a result of altered T cell regulation of IgE production and may contribute to IgE-mediated pathologic responses to respiratory syncytial virus or parainfluenza virus infection. Correction of these deficits may improve host response to infection and enhance vaccine-related protection. Both vitamin A and iron deficiency states have been epidemiologically associated with increased morbidity due to respiratory infection. The impact of preventive therapy with either vitamin A or iron is still uncertain, but such therapy has the potential for diminishing the incidence of respiratory infections and their consequences.