US Naval Medical Research Unit Research Articles

Delayed SARS-COV-2 clearance in infected persons in Ghana.

This study aimed to determine the duration of SARS-CoV-2 clearance in persons in Ghana. The research question was whether the duration of virus clearance in Ghana matched the 14 days recommended by the World Health Organization (WHO); this had direct implications for transmission, which was key in managing the COVID-19 pandemic. This was a retrospective analytical study. All facilities that submitted clinical specimens to Noguchi Memorial Institute for Medical Research (NMIMR) for SARS-CoV-2 diagnosis between March to June 2020 were included in the study. Samples from 480 persons who tested positive for SARS-CoV-2 by RT-PCR from March to June 2020 at NMIMR and submitted at least two follow-up samples were retrospectively analysed. Individuals with two consecutive negative RT-PCR retesting results were considered to have cleared SARS-CoV-2. The median time from the initial positive test to virus clearance was 20 days (IQR: 5-56 days). This was six days longer than the WHO-recommended 14 days, after which infected persons could be de-isolated. Sputum and nasopharyngeal swabs proved more sensitive for detecting viral RNA as the infection progressed. At a significance level of 0.05, age and sex did not seem to influence the time to SARS-CoV-2 clearance. The median time to SARS-CoV-2 clearance in this study was 20 days, suggesting that SARS-CoV-2 infected persons in Ghana take longer to clear the virus. This finding calls for further investigations into whether patients who remain PCR positive continue to be infectious and inform isolation practices in Ghana. The study was supported by the Ministry of Health/ Ghana Health Service through the provision of laboratory supplies, the US Naval Medical Research Unit #3, the World Health Organization, the Jack Ma Foundation and the Virology Department of Noguchi Memorial Institute for Medical Research, University of Ghana. Research projects within Noguchi Memorial Institute for Medical Research contributed reagents and laboratory consumables. However, the authors alone are responsible for the contents of this manuscript.

Advancing science diplomacy: Indonesia and the US Naval Medical Research Unit.

Science diplomacy supposedly builds international cooperation through scientific and technical exchange. In practice, however, there are important but often overlooked instances where it might create conflict instead--as with accusations of espionage surrounding the US Naval Medical Research Unit 2 (NAMRU-2) in Indonesia. Did American science diplomacy backfire in Indonesia and, if so, why? Most literature fails to anticipate this possibility, let alone explain it, since science diplomacy is rarely subject to critical analysis. Rather than shun politics or, similarly, simply blame the demise of NAMRU-2 on the military or avian influenza, I consider both the successes and failures of this research unit in the context of Indonesia's transition to democracy and America's legacy from the Cold War. Based on this history, I propose that the effects of science diplomacy depend on strategic communication and exchange, as well as elite influence and material incentives. Therefore, by challenging the conventional wisdom about science diplomacy, NAMRU-2 can help advance the theory and practice of this potentially useful tool of statecraft.

Establishing a laboratory network of influenza diagnosis in Indonesia: an experience from the avian flu (H5N1) outbreak

Indonesia has been part of the global influenza surveillance since the establishment of a National Influenza Center (NIC) at the National Institute of Health Research and Development (NIHRD) by the Indonesian Ministry of Health in 1975. When the outbreak of avian influenza A (H5N1) occurred, the NIC and US Naval Medical Research Unit 2 were the only diagnostic laboratories equipped for etiology confirmation. The large geographical area of the Republic of Indonesia poses a real challenge to provide prompt and accurate diagnosis nationally. This was the main reason to establish a laboratory network for H5N1 diagnosis in Indonesia. Currently, 44 laboratories have been included in the network capable of performing polymerase chain reaction testing for influenza A. Diagnostic equipment and standard procedures of biosafety and biosecurity of handling specimens have been adopted largely from World Health Organization recommendations.

SURVEILLANCE OF AVIAN INFLUENZA VIRUSES IN MIGRATORY BIRDS IN EGYPT, 2003–09

Migratory (particularly aquatic) birds are the major natural reservoirs for type A influenza viruses. However, their role in transmitting highly pathogenic avian influenza (HPAI) viruses is unclear. Egypt is a "funnel" zone of wild bird migration pathways from Central Asia and Europe to Eastern and Central Africa ending in South Africa. We sought to detect and isolate avian influenza viruses in migratory birds in Egypt. During September 2003-February 2009, the US Naval Medical Research Unit Number 3, Cairo, Egypt, in collaboration with the Egyptian Ministry of Environment, obtained cloacal swabs from 7,894 migratory birds captured or shot by hunters in different geographic areas in Egypt. Samples were processed by real-time reverse transcriptase PCR for detection of the influenza A matrix gene. Positive samples were processed for virus isolation in specific-pathogen-free embryonated eggs and isolates were subtyped by PCR and partial sequencing. Ninety-five species of birds were collected. Predominant species were Green-Winged Teal (Anas carolinensis; 32.0%, n=2,528), Northern Shoveler (Anas clypeata; 21.4%, n=1,686), and Northern Pintail (Anas acuta; 11.1%, n=877). Of the 7,894 samples, 745 (9.4%) were positive for the influenza A matrix gene (mainly from the above predominant species). Thirteen of the 745 (1.7%) were H5-positive by PCR (11 were low-pathogenic avian influenza and two were HPAI H5N1). The prevalences of influenza A was among regions were 10-15%, except in Middle Egypt (4%). Thirty-nine influenza isolates were obtained from PCR-positive samples. Seventeen subtypes of avian influenza viruses (including H5N1 and H7N7) were classified from 39 isolates using PCR and partial sequencing. Only one HPAI H5N1 was isolated in February 2006, from a wild resident Great Egret (Ardea alba). No major die-offs or sick migratory birds were detected during the study. We identified avian influenza virus subtypes not previously reported in Egypt. The HPAI H5N1 isolated or detected indicates that migratory birds may play a role in the dispersal of HPAI virus, but a detailed mechanism of this role needs to be elucidated.

Zika Virus Infection, Cambodia, 2010

To the Editor: Zika virus (ZIKV), a member of the family Flaviviridae, genus Flavivirus, was first isolated from the blood of a sentinel rhesus monkey from the Zika Forest of Uganda in 1948 (1). Since that time, serologic studies and virus isolations have demonstrated that the virus has a wide geographic distribution, including eastern and western Africa; the Indian subcontinent; Southeast Asia; and most recently, Micronesia (2–5). The virus is transmitted primarily through the bite of infected mosquitoes and most likely is maintained in a zoonotic cycle involving nonhuman primates (1), although recent evidence suggests the possibility of occasional sexual transmission in humans (4). Few case reports have described the clinical characteristics of ZIKV infection in humans. Most reports describe a self-limiting febrile illness that could easily be mistaken for another arboviral infection, such as dengue or chikungunya fever. We report a confirmed case of ZIKV infection in Cambodia. Since 2006, the US Naval Medical Research Unit No. 2 (NAMRU-2) has conducted surveillance for acute fever to determine causes of the infection among patients who seek health care at local clinics in Cambodia. Patients were enrolled by the health clinic physician after they gave informed consent in accordance with an institutional review board protocol approved by NAMRU-2 and the National Ethics Committee for Human Research of Cambodia. At enrollment, the physician administered a questionnaire and collected specimens (blood and throat swabs). All items were transported to the NAMRU-2 laboratory in Phnom Penh, where testing was conducted for a variety of viral, bacterial, and parasitic pathogens. In August 2010, a blood specimen was collected from a 3-year-old boy at a health clinic in Kampong Speu Province, Cambodia. The child’s reported clinical symptoms included 4 days of fever and sore throat and cough and a headache for 3 days. A maculopapular rash was not observed, and the boy was not hospitalized. The clinic staff conducted a follow-up interview and reported that the patient recovered fully. ZIKV infection was confirmed in this patient by using PCR, sequencing, and serology and through virus isolation. ELISA for chikungunya and dengue virus IgM and IgG antibodies on acute- and convalescent-phase serum was negative. A universal flavivirus real-time PCR screen that targets the nonstructural (NS) 5 gene (6) determined that the patient’s serum was positive for flavivirus RNA, but subsequent species-specific PCR ruled out 2 other flaviviruses that are highly endemic to the region (dengue and Japanese encephalitis viruses) (7–9). This result was the first nondengue, non–Japanese encephalitis virus flavivirus detected after samples from ≈10,000 enrolled patients were tested. Nucleic acid sequencing of the amplicon isolated by gel purification produced a 100-bp fragment with 100% sequence identity to ZIKV (nucleotide position 8,969 of the NS5 gene of the isolate GenBank accession no. {type:entrez-nucleotide,attrs:{text:EU545988,term_id:189092757}}EU545988). ZIKV infection subsequently was serologically confirmed by hemagglutination-inhibition tests on paired serum samples. The patient’s acute-phase sample was negative, but a convalescent-phase sample gave a positive reaction with ZIKV antigen to a serum dilution of 1:320 and was negative to antigens for the 4 dengue serotypes and yellow fever and West Nile viruses. These results demonstrate that the patient had a clear monotypic flavivirus immune response with seroconversion against ZIKV, indicating a recent primary infection. The most common signs and symptoms reported in confirmed ZIKV infections are fever, headache, malaise, maculopapular rash, fatigue or myalgia, and arthritis and arthralgia (Table). In addition to fever and headache, the patient in this study had a sore throat and cough. Because of the patient’s age, additional information about symptoms was difficult to obtain. Table Reported or observed clinical signs and symptoms in persons with Zika virus infection, 1962–2010 The clinical characteristics exhibited by this case-patient are similar to those of shown in a small cluster of ZIKV infections described in Indonesia during 1977–1978 in which maculopapular rash was not observed (5). Maculopapular rash was reported as a common sign in case-patients from the recent Yap Island outbreak (3), as well as in case reports from Uganda (2), Senegal, and the United States (4), A case report of laboratory-acquired ZIKV infection also noted the lack of maculopapular rash (10). The clinical features of ZIKV infection are similar to those of dengue virus and chikungunya virus infections, and both arboviruses are found in Southeast Asia. In this region, laboratory-based confirmation is essential. The extent of ZIKV infections in Cambodia is unknown; further studies are needed to clarify the prevalence and geographic distribution of ZIKV infection in the country.

Crimean-Congo Hemorrhagic Fever Virus in Ticks from Imported Livestock, Egypt

To the Editor: Crimean Congo hemorrhagic fever, a tick-borne illness caused by Crimean Congo hemorrhagic fever virus (CCHFV), is endemic to Africa, the Balkans, the Middle East, and parts of Asia. The hard ticks (Ixodidae), especially those of the genus Hyalomma, serve as reservoirs and vectors for CCHFV, and a variety of animals, such as cattle, sheep, and camels, are considered amplifying hosts for the virus. Although CCHFV may cause little or no disease in zoonotic hosts, the virus can cause severe disease in humans who may be exposed by tick bites or by contact with blood or tissues from infected patients or animals (1). Surveillance for CCHFV in animal and vector populations provides an opportunity to monitor a disease of potentially severe impact. In North Africa and the Middle East, trade in live animals, meat, and meat products poses noticeable risk to human and animal health (2,3) and can serve as a mobile pool of diseases with potentially large economic and health effects. Animals often originate in distant areas of a country or its neighbors, where they may be exposed to zoonotic pathogens not endemic to their final location, and may collect vectors that carry additional pathogens. As part of a broader study examining occupational risk of exposure to vector-borne and zoonotic pathogens in a high-risk abattoir worker population, we collected ectoparasites from freshly-slaughtered livestock and examined them for CCHFV. This study and was conducted in compliance with the Animal Welfare Act and in accordance with the principles set forth in the Guide for the Care and Use of Laboratory Animals (4). Sample collection took place over a 2-week period in July 2009 at the Muneeb abattoir in the Giza Governorate of Egypt. Ectoparasites were removed from 43 freshly slaughtered animals by using blunt forceps and were placed in glass vials. In total, 342 ectoparasites were collected: 70 (20.5%) from 14 cattle, 52 (15.2%) from 17 buffalo, 6 (1.8%) from 2 sheep, and 214 (62.6%) from 10 camels. Cattle, buffalo, and sheep originated in Egypt; camels were imported from Sudan and Somalia. Ectoparasites were transported to US Naval Medical Research Unit No. 3 in Cairo, Egypt, for taxonomic identification and pathogen detection. Ninety-seven percent (334) of the ectoparasites were ticks from the family Ixodidae. The genus Hyalomma accounted for 254 (76.0%) of these ticks, including nearly all of those collected from sheep (100%) and camels (99.5%) but only 60.4% and 9.1% of those collected from buffalo and cattle, respectively. The remaining ticks of the family Ixodidae belonged to genus Boophilus. After identification, ticks were grouped into pools by species, sex, and animal source. RNA was then extracted by using the QIAamp Viral RNA Kit (QIAGEN, Valencia, CA, USA). CCHFV small fragment RNA was detected with SuperScript III Platinum SYBR Green One-Step qRT-PCR (Invitrogen, Carlsbad, CA, USA) and published primers as described (5). Of 138 pools tested (258 ticks of the genera Hyalomma and Boophilus), 6 pools were positive for CCHFV. These 6 pools contained ticks collected from 1 camel imported from Somalia and 4 from Sudan. One positive pool comprised female H. excavatum (Koch, 1844), and 5 comprised female H. dromedarii (Koch, 1844), both proven vectors of CCHFV. Sequence analysis showed that each CCHFV-positive pool contained an identical yet previously unrecorded 229-bp RNA fragment (GenBank accession no. {type:entrez-nucleotide,attrs:{text:JF706233,term_id:371444381}}JF706233; Figure). This fragment had 92% identity with many published CCHFV isolates (BLAST analysis [www.ncbi.nlm.nih.gov/BLAST], GenBank nonredundant database); however, most base changes were synonymous substitutions. Translated protein queries (tblastx) identified an amino acid (serine at codon 26) in this new variant that differed from all but 1 ({type:entrez-nucleotide,attrs:{text:AJ010648.1,term_id:10638944}}AJ010648.1) of the 100 most similar published sequences. The functional consequence of a S26N substitution is unknown but may be minimal because of the similar physicochemical properties of asparagine and serine. Figure Phylogenetic relationship of 110 Crimean-Congo hemorrhagic fever virus sequences obtained from this study (6 tick pools), the positive control, and 99 published isolates from GenBank. Sequences were aligned by using ClustalX (www.clustal.org), and a phylogenetic ... Despite the low number of camels sampled in this study, 5 of the 10 camels were found to harbor ticks carrying RNA from an undocumented variant of CCHF. Although none of the domestic animals harbored infected ticks, it is not possible to conclude if these data reflect importation of CCHFV or infection acquired within Egypt because details about conditions under which animals were kept before slaughter are unavailable. Previous serologic studies in Egypt have shown antibodies to CCHFV were prevalent among imported camels at a quarantine station in Aswan governorate (6) and among domestic cattle, buffalo, sheep, and goats in Sharkia Governorate (7). We plan to further investigate the presence of CCHFV within camel and ectoparasite populations in Egypt by expanding protocol activities to a camel market in the same area as the abattoir.

Pandemic H1N1 influenza at the 2009 Hajj: understanding the unexpectedly low H1N1 burden

The Kingdom of Saudi Arabia (KSA) administered the 2009 Hajj, the largest annual mass gathering of people from about 160 countries, amid a declared global H1N1 pandemic. The unexpectedly low incidence of H1N1 during the Hajj is of concern.1 The official report for the 2009 Hajj refers to laboratory-confirmed, symptomatic pilgrims who sought clinical care in Hajj-related clinical facilities during the five-day period of Hajj. Because of the short duration of the Hajj rituals (5 days), the commitment of pilgrims to perform the Hajj rituals, and the mild clinical course of 2009 H1N1 pandemic influenza for most infected persons, it is possible that symptomatic pilgrims may have deferred contact with the healthcare system, unless symptoms became severe. This could explain the high case fatality observed during the Hajj despite the low disease burden. Furthermore, illnesses that developed after the strictly defined five-day Hajj rituals are not included in the statistics released on the final day of Hajj. For the 2009 Hajj, KSA collaborated with the US Centers for Disease Control and Prevention, the World Health Organization Eastern Mediterranean Regional Office, and the US Naval Medical Research Unit #3 based in Cairo on H1N1 surveillance. The activities included clinic-based sentinel laboratory surveillance in Hajj-specific clinics and community-based laboratory surveillance activities at the Jeddah Airport Hajj Terminal during the arrival and departure of pilgrims. Given the one- to four-day incubation period of influenza viruses, the departure survey of about 3000 pilgrims (about 0.01% of an estimated 2.5–3 million pilgrims) conducted during the first five days after the end of Hajj will help assess the burden of influenza infections acquired during the preceding Hajj period. Because the laboratory tests in these surveillance activities covered tests for all influenza viruses, real-time reporting of the test results was not feasible. Participants in any mass gathering may not all travel in the immediate period before or after the mass gathering event, or may use multiple modes of transportation that limits surveillance data capture. Extended surveillance timeframes implemented at diverse entry and exit points are required to capture indicators of disease spread or amplification. Post-event surveillance should be an integral component of mass gathering surveillance systems to understand the full extent of diseases acquired during an event. Given that 75% of the pilgrims originate from the 40 lower or low-to-middle income countries2 with limited surveillance infrastructure, post-Hajj surveillance in home countries of pilgrims remains a challenge. Rapid one-time disease surveillance among diverse international populations is feasible during mass gatherings and can greatly enhance and ultimately assure global public health security.3

Identification of a Rotavirus G12 Strain, Indonesia

To the Editor: Group A rotaviruses are the most common etiologic agents of acute gastroenteritis in infants and young children, each year resulting in ≈100 million diarrhea episodes and 600,000 deaths worldwide (1). The genome of rotavirus comprises 11 segments of double-stranded RNA, which encode 6 structural viral proteins (VPs) and 6 nonstructural proteins (NSPs). Recent scientific reports have identified novel rotavirus strains, such as G12 (2–5), which were first described in 1987 among Filipino children with diarrhea (6). In Indonesia, a rotavirus study showed that a broad variety of VP7 types (G1, G2, G3, G4, G8, G9) and VP4 types (P[4], P[6], P[8], P[9], P[10], P[11]), especially G9 and P[8] and G9P[8], were the genotype combinations most frequently encountered (7). From 2005 through 2008, we conducted a nationwide surveillance study among children who had diarrhea to determine etiologies among Indonesian children seeking health services for diarrhea at hospitals and health clinics. Patients were enrolled after obtaining consent from parents/guardians of those eligible in accordance with an institutional review board protocol approved by the US Naval Medical Research Unit No. 2 (NAMRU-2) and the Ethical Committee of the Indonesian National Health Research and Development Institute. Stool specimens and clinical enrollment data were collected for each eligible patient, and all collected items were transported to NAMRU-2 in Jakarta, Indonesia. In December 2007, a stool specimen was collected from a 14-day-old afebrile infant brought to Sumber Waras Hospital in West Jakarta with diarrhea, vomiting, moderate dehydration, and malnutrition. This patient was infected with the rotavirus G12 strain, was hospitalized for 6 days, and was discharged after recovering fully. Bacterial cultures and ova/parasite evaluations were negative for enteric pathogens. Rotavirus was detected in this specimen and genotyped by multiplex, seminested reverse transcription–PCR (RT-PCR) targeting the VP4 and VP7 genes (8,9). The specimen was typed as P[4]P[6] but was G-nontypeable. Primers to detect G12 were then used for RT-PCR and identified the proper G12 amplicon size (2,3). By use of published primers (9), sequencing of the VP7 gene segment confirmed the presumptive G12 genotype. Sequencing reactions were performed by using the BigDye Terminator v3.1 Cycle Sequencing Kit (Applied Biosystems, Foster City, CA, USA) on the Applied Biosystems 3130xl sequencer. Sequence analysis was done by using Sequencher 4.8 version (Gene Codes Corporation, Inc., Ann Arbor, MI, USA). Nucleotide sequences were submitted to GenBank for a BLASTN search (http://blast.ncbi.nlm.nih.gov) on the National Center for Biological Information website. We then created alignments of nucleotides and deduced amino acid sequences and compared them with a selection of reference strains from the GenBank database. Genetic relationships among G12 were determined by using PAUP version 4.0 beta 10 software (http://paup.csit.fsu.edu). A phylogenetic tree was constructed on the basis of nucleotides 1–971 of the VP7 gene by using the neighbor-joining method and applying the Kimura 2-parameter method with 1,000 bootstrap replicates of the neighbor-joining model. The BLASTN search of the VP7 989 nucleotide sequence of the putative G12 Indonesian rotavirus (Indo SWJ0806) showed 98% similarity with published VP7 sequences of rotavirus G12 strains from Japan (CP727; GenBank accession no.{type:entrez-nucleotide,attrs:{text:AB125852,term_id:49065032,term_text:AB125852}}AB125852), Argentina (Arg721; GenBank accession no. {type:entrez-nucleotide,attrs:{text:EU496255,term_id:169835103,term_text:EU496255}}EU496255), and Thailand (T152; GenBank accession no. {type:entrez-nucleotide,attrs:{text:AB071404,term_id:19912798,term_text:AB071404}}AB071404). The Indonesia G12 clustered into the lineage II composed of rotavirus G12 reference strains from Japan, Argentina, South Korea, and Thailand (Figure). Lineage II is a minority cluster when compared with lineage III, which consists of rotavirus G12 from the United States (US6588, Se585), Saudi Arabia (MD844), India (13B2), Bangladesh (RV161), and other Thailand strains (MS051) (4). The nucleotide sequence divergence between lineage II and lineage III ranges from 2.6% to 3.2%. Analysis of the deduced amino acid sequence alignment on the neutralization epitopes that code for the antigenic regions A, B, and C show high conservation of the most immunodominant sites (data not shown). Antigenic regions A, B, C, D, E, and F of Indonesia SWJ0806 show 100% amino acid similarity to Japan G12 strains; K12 and CP727 (9). The amino acid residue at position 142 of the antigenic region B has characterized lineage I and II (Val) and lineage III (Leu). Figure Phylogenetic analysis of the viral protein (VP) 7 genotype G12 rotavirus of Indonesia with reference strains downloaded from GenBank. The GenBank accession numbers of each strain appear next to the strain. The multiple alignment was constructed by using ... Phylogenetic analysis showed that the virus clusters into lineage II and that the deduced amino acid sequence is highly conserved compared with other reported rotavirus G12 strains identified. The combination of the P[6] genotype in this rotavirus strain suggests the possibility of a zoonotic transmission (10). Continued surveillance for rotavirus is an essential component of a country’s public health infrastructure and diarrhea prevention programs. Rotavirus genotyping from the data obtained provides necessary information for vaccine development and identification of novel and emerging rotavirus strains.

Possible Avian Influenza (H5N1) from Migratory Bird, Egypt

Possible Avian Influenza (H5N1) from Migratory Bird, Egypt

Serogroup X in Meningococcal Disease, Western Kenya

To the Editor: Although >12 different serogroups of Neisseria meningitidis exist, most disease outbreaks across the African meningitis epidemic belt are caused by serogroup A and, less frequently, by serogroups C and W135 (1). N. meningitidis serogroup X was first described in the 1960s and has been found to cause a few cases of invasive disease across North America, Europe, and Africa (2). In Africa, small serogroup X outbreaks have been described in Ghana (9 cases over a 2-year period) and in Niger (134 cases between 1995 and 2000) (3,4). In 2006, however, 51% of 1,139 confirmed cases of meningococcal meningitis in Niger were found to be caused by serogroup X (5). Before the 2005-06 meningococcal epidemic season, no published reports had described serogroup X isolates in East Africa. We report the involvement of N. meningitidis serogroup X in an outbreak of meningococcal disease in Western Kenya. In January 2006, the Ministry of Health of Kenya and Medecins sans Frontieres were notified of a suspected meningococcal disease outbreak in West Pokot District, bordering Uganda, in Western Kenya. On the basis of the initial outbreak investigation, the outbreak was assessed to have begun in late December 2005. Subsequent active surveillance, using the same clinical case definition of sudden fever onset with stiff neck, altered mental status, or both, showed 74 suspected cases through mid-March 2006, with a case-fatality rate of 20%. No cases were reported after March 2006. Over the course of the outbreak, cerebrospinal fluid samples were obtained from 18 patients. Due to low population density, poor access to seminomadic populations, and the limited nature of the outbreak (relatively small numbers dispersed over a wide geographic region), obtaining specimens from untreated patients in West Pokot proved difficult. Three of the 5 first samples were found to show gram-negative diplococci on staining, the next 2 were negative on Pastorex rapid latex agglutination test (Bio-Rad Laboratories, Hercules, CA, USA) (during the outbreak investigation), and a subsequent 13 were sent to the African Medical and Research Foundation (AMREF) laboratory in Nairobi, Kenya, for culture and susceptibility testing. From these 13 specimens, 2 yielded a pure growth of N. meningitidis serogroup X, while no growth was observed for the remaining 11 specimens. These 2 cultures were subsequently confirmed as serogroup X by the World Health Organization Collaborating Centre for Meningococci in Oslo, Norway. Multilocus sequence typing and sequencing of the porA and fetA genes as described (http://pubmlst.org/neisseria/), showed that the infecting strain belonged to a new sequence type, ST-5403, and that it was subtype P1.19,26 and FetA type F3-27. This sequence type is unrelated to other serogroup X isolates from Africa, including those from the latest serogroup X outbreak in Niger, but it resembles a sequence type isolated in the United States in the 1970s. In addition to the testing at AMREF and in the Oslo laboratory, the 13 samples were also analyzed by PCR at the US Naval Medical Research Unit No. 3 in Cairo, Egypt. Overall, 5 of these 13 specimens were positive for serogroup X (including the 2 samples found to be serogroup X at AMREF and confirmed by PCR in Oslo) and 1 each was positive for serogroups C, W135, and Y. At the same time as this outbreak in Western Kenya, a meningococcal meningitis outbreak was being monitored across the border in the Karamoja region of northeastern Uganda. Seminomadic populations move freely across the 2 countries, and we can assume that there was 1 meningitis outbreak that started in eastern Uganda and spread to Western Kenya. Although initial laboratory testing in Uganda suggested the presence of serogroup A, among 23 specimens subsequently sent to the Oslo laboratory, 11 were identified as serogroup X by PCR and 3 were serogroup W135 (6). Therefore, the outbreaks in both Kenya and Uganda involved multiple N. meningitidis serogroups. In West Pokot, Kenya, the Ministry of Health and Medecins sans Frontieres conducted a vaccination campaign using the trivalent polysaccharide vaccine against serogroups A, C, and W135. Before 2006, previous disease outbreaks caused by serogroup X had not reached the magnitude of those caused by serogroups A, C, or W135; they tended to evolve independently of the occurrence of both serogroups A and C and to be self-limited (3,4). Although most of Kenya is not included in the African meningitis belt, large epidemics of meningococcal disease have been reported previously (7). In conclusion, we would like to highlight the presence of N. meningitidis serogroup X in East Africa, its potential involvement in disease outbreaks, and the difficulties it may cause for laboratory confirmation and, consequently, for making an appropriate epidemic response.

Evolution of infection control in Egypt: Achievements and challenges

The high prevalence of hepatitis C virus (HCV) infection in Egypt highlighted the urgent need for implementing infection control (IC) programs in Egypt. The Ministry of Health and Population (MOHP), in collaboration with the US Naval Medical Research Unit No. 3, and the World Health Organization (WHO), developed a national plan to initiate an IC program with the objectives of improving quality of care and reducing transmission of hospital-acquired infections. The strategic plan for this program included setting up an organizational structure, developing IC national guidelines, training health care workers, promoting occupational safety, and establishing a system for monitoring and evaluation. Implementation of the program started in late 2001. The achievements to date include developing a national organizational structure, IC guidelines, and a comprehensive IC training program. To date, a total of 72 hospitals in 13 governorates have been enrolled in the program, and 235 IC professionals have been trained. Many challenges were faced, including administrative, financial, and motivational difficulties. Future plans include expansion of the program to cover all 27 governorates of Egypt and establishment of a surveillance system for hospital-acquired infections. The process of developing the IC program in Egypt may serve as a model for other resource-limited countries that seek to initiate similar programs.

Clinical features associated with HIV-1 infection in adult patients diagnosed with tuberculosis in Djibouti, Horn of Africa

The US Naval Medical Research Unit headed up a retrospective study of all adult patients diagnosed in 1991 with tuberculosis (TB) at the Paul Faure Hospital Center in Djibouti city. 92% (1844) of the medical records had complete information on demographics, clinical, and radiological characteristics associated with TB and HIV serological status. 106 (5.7%) patients had HIV-1 infection. Two patients had both HIV-1 and HIV-2 infection. Clinical predictors for HIV seropositivity included peritonitis (odds ratio [OR] = 5.08; p = 0.0164) and pleural effusion (OR = 2.15; p = 0.0037). Ethiopian nationality also predicted HIV infection among TB patients (OR = 2.13; p = 0.0002). The high percentage of glandular TB in this area of Africa, even before the HIV epidemic, may account for the lack of statistical association between HIV positivity and peripheral lymphadenopathy. These findings indicate that newly diagnosed TB adult patients with peritonitis or pleural effusion are rather likely to also have HIV infection. Physicians should suspect HIV infection in such patients, since they may be at high risk of exposure to body fluids during surgery for peritonitis and drainage of pleural effusion. The high variance makes peritonitis and pleural effusion relatively poor predictors of HIV infection, however.

Surveillance for Exposure to HTLV-I in Egyptian Infants and Children with Various Malignancies

Journal Article Surveillance for Exposure to HTLV-I in Egyptian Infants and Children with Various Malignancies Get access A. S. Khalifa, A. S. Khalifa Pediatrics and Microbiology Department, Ain Shams University, and US Naval Medical Research Unit No.3, Cairo, Egypt Reprints and correspondence: Dr. Ahmed S. Khalifa, Pediatrics Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt. Search for other works by this author on: Oxford Academic PubMed Google Scholar Rasha Khalil, Rasha Khalil Pediatrics and Microbiology Department, Ain Shams University, and US Naval Medical Research Unit No.3, Cairo, Egypt Search for other works by this author on: Oxford Academic PubMed Google Scholar Azza Abdel Gawad, Azza Abdel Gawad Pediatrics and Microbiology Department, Ain Shams University, and US Naval Medical Research Unit No.3, Cairo, Egypt Search for other works by this author on: Oxford Academic PubMed Google Scholar N. T. Constantine, N. T. Constantine Pediatrics and Microbiology Department, Ain Shams University, and US Naval Medical Research Unit No.3, Cairo, Egypt Search for other works by this author on: Oxford Academic PubMed Google Scholar J. N. Woody J. N. Woody Pediatrics and Microbiology Department, Ain Shams University, and US Naval Medical Research Unit No.3, Cairo, Egypt Search for other works by this author on: Oxford Academic PubMed Google Scholar The Journal of Infectious Diseases, Volume 162, Issue 4, October 1990, Pages 995–996, https://doi.org/10.1093/infdis/162.4.995 Published: 01 October 1990

Low incidence of erythrocyte G-6-P D deficiency in Vietnamese and Montagnards of South Vietnam.

Vox SanguinisVolume 20, Issue 6 p. 555-558 Low Incidence of Erythrocyte G-6-P D Deficiency in Vietnamese and Montagnards of South Vietnam1 D. B. Youel, Corresponding Author D. B. Youel US Naval Medical Research Unit No. 2 Detachment and US Naval Support Activity Station Hospital, DaNang; Accepted: November 17, 1970. US Naval Hospital, San Diego, Cal. (USA). Publications Office, NAMRU-2, Box 14, APO San Francisco 96263.Search for more papers by this authorG. T. Strickland, Corresponding Author G. T. Strickland US Naval Medical Research Unit No. 2 Detachment and US Naval Support Activity Station Hospital, DaNang; Accepted: November 17, 1970. US Naval Hospital, San Diego, Cal. (USA). Publications Office, NAMRU-2, Box 14, APO San Francisco 96263.Search for more papers by this authorBui An Binh, Corresponding Author Bui An Binh US Naval Medical Research Unit No. 2 Detachment and US Naval Support Activity Station Hospital, DaNang; Accepted: November 17, 1970. US Naval Hospital, San Diego, Cal. (USA). Publications Office, NAMRU-2, Box 14, APO San Francisco 96263.Search for more papers by this authorR. Clarkson, Corresponding Author R. Clarkson US Naval Medical Research Unit No. 2 Detachment and US Naval Support Activity Station Hospital, DaNang; Accepted: November 17, 1970. US Naval Hospital, San Diego, Cal. (USA). Publications Office, NAMRU-2, Box 14, APO San Francisco 96263.Search for more papers by this authorR. Q. Blackwell, Corresponding Author R. Q. Blackwell US Naval Medical Research Unit No. 2 Detachment and US Naval Support Activity Station Hospital, DaNang; Accepted: November 17, 1970. US Naval Hospital, San Diego, Cal. (USA). Publications Office, NAMRU-2, Box 14, APO San Francisco 96263.Search for more papers by this author D. B. Youel, Corresponding Author D. B. Youel US Naval Medical Research Unit No. 2 Detachment and US Naval Support Activity Station Hospital, DaNang; Accepted: November 17, 1970. US Naval Hospital, San Diego, Cal. (USA). Publications Office, NAMRU-2, Box 14, APO San Francisco 96263.Search for more papers by this authorG. T. Strickland, Corresponding Author G. T. Strickland US Naval Medical Research Unit No. 2 Detachment and US Naval Support Activity Station Hospital, DaNang; Accepted: November 17, 1970. US Naval Hospital, San Diego, Cal. (USA). Publications Office, NAMRU-2, Box 14, APO San Francisco 96263.Search for more papers by this authorBui An Binh, Corresponding Author Bui An Binh US Naval Medical Research Unit No. 2 Detachment and US Naval Support Activity Station Hospital, DaNang; Accepted: November 17, 1970. US Naval Hospital, San Diego, Cal. (USA). Publications Office, NAMRU-2, Box 14, APO San Francisco 96263.Search for more papers by this authorR. Clarkson, Corresponding Author R. Clarkson US Naval Medical Research Unit No. 2 Detachment and US Naval Support Activity Station Hospital, DaNang; Accepted: November 17, 1970. US Naval Hospital, San Diego, Cal. (USA). Publications Office, NAMRU-2, Box 14, APO San Francisco 96263.Search for more papers by this authorR. Q. Blackwell, Corresponding Author R. Q. Blackwell US Naval Medical Research Unit No. 2 Detachment and US Naval Support Activity Station Hospital, DaNang; Accepted: November 17, 1970. US Naval Hospital, San Diego, Cal. (USA). Publications Office, NAMRU-2, Box 14, APO San Francisco 96263.Search for more papers by this author First published: June 1971 https://doi.org/10.1111/j.1423-0410.1971.tb00467.xCitations: 5 1 This work was supported by the Bureau of Medicine and Surgery, Work Unit MR005.20–0099. The opinions and assertions contained herein are those of the authors and are not to be construed as official or reflecting the views of the US Navy Department or the US Naval Service at large. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume20, Issue6June 1971Pages 555-558 RelatedInformation

Precocious synthesis of adult haemoglobin in Chinese neonates in Taiwan.

Vox SanguinisVolume 20, Issue 4 p. 381-383 Precocious Synthesis of Adult Haemoglobin in Chinese Neonates in Taiwan1 R. Q. Blackwell, Corresponding Author R. Q. Blackwell Biochemistry Department, US Naval Medical Research Unit No. 2, Taipei, Taiwan and Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan US Naval Medical Research Unit No. 2, Box 14, APO San Francisco, CA 96263 (USA) Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan (Republic of China)Search for more papers by this authorJ. T.-H. Huang, Corresponding Author J. T.-H. Huang Biochemistry Department, US Naval Medical Research Unit No. 2, Taipei, Taiwan and Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan US Naval Medical Research Unit No. 2, Box 14, APO San Francisco, CA 96263 (USA) Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan (Republic of China)Search for more papers by this authorC.-S. Liu, Corresponding Author C.-S. Liu Biochemistry Department, US Naval Medical Research Unit No. 2, Taipei, Taiwan and Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan US Naval Medical Research Unit No. 2, Box 14, APO San Francisco, CA 96263 (USA) Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan (Republic of China)Search for more papers by this authorWen-Tsuo Chiang, Corresponding Author Wen-Tsuo Chiang Biochemistry Department, US Naval Medical Research Unit No. 2, Taipei, Taiwan and Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan US Naval Medical Research Unit No. 2, Box 14, APO San Francisco, CA 96263 (USA) Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan (Republic of China)Search for more papers by this author R. Q. Blackwell, Corresponding Author R. Q. Blackwell Biochemistry Department, US Naval Medical Research Unit No. 2, Taipei, Taiwan and Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan US Naval Medical Research Unit No. 2, Box 14, APO San Francisco, CA 96263 (USA) Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan (Republic of China)Search for more papers by this authorJ. T.-H. Huang, Corresponding Author J. T.-H. Huang Biochemistry Department, US Naval Medical Research Unit No. 2, Taipei, Taiwan and Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan US Naval Medical Research Unit No. 2, Box 14, APO San Francisco, CA 96263 (USA) Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan (Republic of China)Search for more papers by this authorC.-S. Liu, Corresponding Author C.-S. Liu Biochemistry Department, US Naval Medical Research Unit No. 2, Taipei, Taiwan and Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan US Naval Medical Research Unit No. 2, Box 14, APO San Francisco, CA 96263 (USA) Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan (Republic of China)Search for more papers by this authorWen-Tsuo Chiang, Corresponding Author Wen-Tsuo Chiang Biochemistry Department, US Naval Medical Research Unit No. 2, Taipei, Taiwan and Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan US Naval Medical Research Unit No. 2, Box 14, APO San Francisco, CA 96263 (USA) Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan (Republic of China)Search for more papers by this author First published: April 1971 https://doi.org/10.1111/j.1423-0410.1971.tb00457.x 1 This work was supported by the Bureau of Medicine and Surgery, Work Unit MR005.20–0099, Accepted: November 17, 1970. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Volume20, Issue4April 1971Pages 381-383 RelatedInformation

CEREBRAL SALT-WASTING ASSOCIATED WITH THE GUILLAIN-BARR'E SYNDROME.

INAPPROPRIATE secretion of antidiuretic hormone has been implicated as the cause of the hyponatremia and renal salt-wasting associated with certain cases of intracranial and intrathoracic disease. Cases of traumatic, infectious, and neoplastic intracranial disease, and of neoplastic thoracic disease have been associated with the salt-wasting syndrome. 1-6 The following is a report of the simultaneous occurrence in a patient of an illness clinically indistinguishable from the Guillain-Barre syndrome and of an electrolyte disturbance marked by transient loss of renal sodium-conserving ability, plasma hypo-osmolality, and plasma hyponatremia. Immunologic features of this patient's illness suggested to us that the etiology of the polyradiculoneuropathy was hypersensitivity to viral antigens. Report of a Case A 32-year-old Taiwanese man, a virology technician at the US Naval Medical Research Unit No. 2 (NAMRU-2), was admitted to Taiwan University Hospital on Sept 16, 1961, with the chief complaint of walking disturbance and pain in the left