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We identified 40 (32 definite and 8 possible) nosocomial viral respiratory tract infections in 38 patients during the study period, including 17 patients admitted to the adult hospital and 23 patients admitted to the pediatric hospital (5 and 44 cases per 10 000 admissions to the adult and pediatric hospital, respectively) (Table 2). The median age of cases in the adult and pediatric hospitals was 56 and 1 year of age, respectively. Eleven (28%) of the cases were immunocompromised. In 6 cases, patients were in an ICU when they developed symptoms. In 5 other cases, after the nosocomial respiratory viral infection was identified, the patient was transferred to an ICU. The mean interval from symptom onset to ICU admission was 1.8 days. Two of these 5 cases, and 4 of the 10 cases already in an ICU, required mechanical ventilation after a mean interval of 5 and 0 days after symptom onset, respectively. In 17 of the 40 cases (43%), antibiotics were initiated at the time of symptom onset, and in 82% of the cases, the antibiotics were continued despite positive test results for the respiratory viral infection. It is unclear how many of these cases had bacterial coinfection. Fever (defined as temperature >38°C) and/or cough were the initial symptoms in over half of the cases (78% and 60%, respectively). Fever was the most common symptom among the pediatric patients (83%), whereas cough was the most common symptom among adult patients (77%). Congestion and rhinorrhea were present in 48% and 38% of patients, respectively. No adult patients had documented symptoms of vomiting or conjunctivitis associated with their viral infection; however, both were documented in pediatric patients (15% and 2.5%, respectively). No adult patients had a single isolated symptom at presentation, but fever was the only presenting symptom in 3 of the 23 pediatric cases.
Forty-four viruses were identified in the 40 cases, including 4 cases of viral coinfection (Table 3). The most common viruses identified were rhino/enterovirus in both adults (61%) and pediatric cases (54%). Influenza A only accounted for 3 cases (6.8%); no nosocomial influenza B cases were identified. During the study period, influenza activity was widespread in Rhode Island March 2, 2015 through April 1, 2016 per data from the Rhode Island Department of Health. Although 63% of cases occurred in the fall and winter, they were identified throughout the year (Figure 1).
Two adult and 3 pediatric patients (13%) died during the hospitalization involving rhino/enterovirus (2 adults, 1 pediatric patient), metapneumovirus (1 pediatric patient), and RSV (1 pediatric patient). The 3 pediatric patients were under 2 years of age. It is difficult to ascribe mortality to such infections in patients with multiple comorbidities; however, 1 pediatric patient with multiple congenital abnormalities decompensated shortly after the viral infection was diagnosed leading to intubation and extracorporeal membrane oxygenation (ECMO). The patient died 1 month after the respiratory virus testing was positive. Another pediatric patient with a hematologic malignancy decompensated shortly after the viral infection was diagnosed leading to intubation and ECMO. The patient died 11 days after respiratory virus testing was positive.
This was a retrospective, Institutional Review Board-approved study of patients who developed laboratory-confirmed respiratory viral infections and whose symptoms began during hospitalization at Rhode Island Hospital and Hasbro Children’s Hospital (HCH) between April 1, 2015 and April 1, 2016. Rhode Island Hospital is licensed for 719 beds, 87 of which are licensed for HCH. The two hospitals are located in adjoining buildings on the same campus as part of the Lifespan Hospital System.
A nosocomial respiratory viral infection was defined as a hospitalized patient who had a positive respiratory viral panel ([RVP] Luminex, Austin, TX), rapid influenza test (Xpert; Cepheid, Sunnyvale, CA), or rapid respiratory syncytial virus (RSV) test (Xpert; Cepheid) of a nasopharyngeal or bronchoscopic lavage specimen. The RVP assay included testing for influenza A and B, RSV A and B, coronavirus, parainfluenza, human metapneumovirus, adenovirus, as well as rhinovirus and enterovirus; however, the assay did not distinguish the latter 2 viruses, which heretofore will be noted as rhino/enterovirus. Hospitalized patients with a positive result in one of these tests during the study period were identified using our institutional infection control software system (TheraDoc; Premier, Charlotte, NC). A definite nosocomial respiratory viral infection was defined as a patient whose number of days from hospital admission to symptom onset exceeded the upper range for the incubation period of the identified virus (Table 1). A possible nosocomial respiratory viral infection case was defined as a patient in whom the number of days from hospital admission to symptom onset was within the range of the incubation period for the identified virus who were admitted without clinical signs or symptoms of a respiratory infection. A patient could be included more than once during the hospitalization if they had complete resolution of symptoms ascribed to the respiratory viral infection, recurrence of symptoms compatible with such an infection, and the time interval was greater than the above-noted incubation period. If the second such episode was due to a different virus, it was considered a definite case, and if it was due to the same virus, it was considered a possible case. Cases were assigned to a season based on the date when the symptoms of a respiratory viral infection were first documented in the medical record. Estimates of the incidence of nosocomial viral infections yearly in US acute care adult and pediatric hospitals were based on the number of such infections identified in the current study and the number of admissions to these hospitals during the 2014 fiscal reporting year based on data from the American Hospital Association.
A literature review was performed using the following PubMed search terms: nosocomial; hospital-acquired; and respiratory viral infections. Only studies written in the English language were included. Studies were excluded in our comparative analysis of the incidence of respiratory viral infections if the study was an outbreak investigation or if the reported incidence included nonrespiratory viral infections.
Members of the Paramyxoviridae family are pleomorphic enveloped viruses divided into two subfamilies, Paramyxovirinae and Pneumovirinae. Paramyxovirinae has recently been subdivided into seven genera: Aquaparamyxovirus, Avulavirus, Ferlavirus, Henipavirus, Morbillivirus, Respirovirus, and Rubulavirus (http://ictvonline.org/virusTaxonomy.asp?version=2012). Viruses of this family affect a wide range of animals, including primates, birds, carnivores, ungulates, snakes, cetaceans and humans, and cause a wide variety of infections, such as measles, mumps, pneumonia and encephalitis in humans, and distemper, peste des petits ruminants, Newcastle disease and respiratory tract infections in animals. However, several paramyxoviruses (PVs) have not been classified into any of these seven genera, including Nariva virus (NarPV), Mossman virus (MosPV), Beilong virus (BeiPV), J virus (JPV),, Tupaia paramyxovirus (TupPV) and Tailam virus
, all of which belong to a group of novel paramyxoviruses isolated from wild animals, as well as Salem virus isolated from horses. Among them, only JPV has been shown to be pathogenic, causing extensive haemorrhagic lesions in rodents. Horizontal transmission is the principal mode of intraspecies PV infection, suggesting that contaminated faeces, urine or saliva may be responsible for spillover to other species.
Bats have a close evolutionary relationship with several genera of mammalian paramyxoviruses. Otherwise, bat-borne paramyxoviruses are in close relationship to known paramyxoviruses of mammalian. These small mammals are known to harbour a broad diversity of PVs, including emergent henipaviruses (Nipah virus and Hendra virus) and rubulaviruses [Menangle virus, Tioman virus, Mapuera virus, and Tuhoko virus 1, 2 and 3 (ThkPV-1, ThkPV-2 and ThkPV-3)]. A very broad diversity of paramyxoviruses, including Henipa-, Rubula-, Pneumo- and Morbilli-related viruses, have been detected in six of ten tested bat families. Whereas most of the viruses identified in bats do not seem to cause clinical disease in these animals, there have been reports of rabid bats, and of unusually large numbers of animals succumbing to infection by rabies virus.
As part of a large-scale investigation of viral diversity in bats and of associated zoonotic risks, we have previously detected a bat paramyxovirus in one insectivorous African sheath-tailed bat (Coleura afra), exhibiting several hemorrhagic lesions at necropsy. We therefore examined occurrence of this bat paraymxovirus in other bats.
Viruses are ubiquitous in the environment and are the most common source of infection among immunocompetent individuals. Despite their pervasiveness, viral infections are generally not considered to be of clinical significance among the critically ill, unless the patient is significantly immuncompromised. Much is known about the progression of viral infections as opportunistic pathogens among immunocompromised patients while little is known about their role in patients who are immunocompetent before hospitalization. Even among patients with no history of immunosuppression, reactivation of viral herpes viruses (cytomegalovirus (CMV) and herpes simplex virus (HSV)) has been documented in critically ill–. This suggests that at least for some critically ill patients with no pre-hospital diagnosis of immunosuppression, newly acquired or reactivation of viral infections during hospitalization can be clinically significant in this patient population.
Using a large population based database, we sought to examine the association of viral infections to the outcomes of ICU patients with no evidence of infection or immunosuppression on admission, and to identify potential variables amenable to intervention. We hypothesize that acquired viral infections during hospitalization may carry their own risk for adverse outcomes among patients in the intensive care unit.
A population based retrospective cohort study using the University HealthSystem Consortium (UHC) Database, specifically searching the Resource Manager and Clinical Database within the UHC system, was conducted. The UHC is comprised of 103 academic institutions and 210 affiliate institutions representing over 90% of all academic medical centers in the United States. The UHC database is an administrative database, comprised of International Classification of Disease-9 (ICD-9) diagnosis and procedure codes. At present, it is the only population based dataset to contain information on the critically ill and their exposure to viral and bacterial infections.
Only patients without a diagnosis of infection present on admission were included in the study. The inclusion criteria included immunocompetent ICU patients greater than or equal to eighteen years of age admitted to the hospital between the third quarter, 2006, and second quarter, 2009. Patients with a primary or secondary ICD 9 code signifying a history of organ transplantation, human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), autoimmune disease, leukemia, pancytopenia, or lymphoma were excluded. Immunocompetency was defined as the absence of the aforementioned diagnoses. A total 209,695 patients met the study criteria.
The Paramyxoviridae family within the order of Mononegavirales includes a large number of human and animal viruses that are responsible for a wide spectrum of diseases. Measles virus (MV) is one of the most infectious human viruses known, and has been targeted by the World Health Organization for eradication through the use of vaccines. The paramyxovirus family includes several other viruses with high prevalence and public health impact in humans, like respiratory syncytial virus (RSV), human metapneumovirus (HMPV), mumps virus (MuV), and the parainfluenza viruses (PIV). In addition, newly emerging members of the Paramyxoviridae family – hendra and nipah virus – have caused fatal infections in humans upon zoonoses from animal reservoirs,,. In animals, Newcastle disease virus (NDV) is and Rinderpest virus (RPV) was among the viruses with the most devastating impact on animal husbandry. Members of the Paramyxoviridae family switch hosts at a higher rate than most other virus families and infect a wide range of host species, including humans, non-human primates, horses, dogs, sheep, pigs, cats, mice, rats, dolphins, porpoises, fish, seals, whales, birds, bats, and cattle. Thus, the impact of paramyxoviruses to general human and animal welfare is immense.
The Paramyxoviridae family consists of two subfamilies, the Paramyxovirinae and the Pneumovirinae. The subfamily Paramyxovirinae includes five genera: Rubulavirus, Avulavirus, Respirovirus, Henipavirus and Morbillivirus. The subfamily Pneumovirinae includes two genera: Pneumovirus and Metapneumovirus
. Classification of the Paramyxoviridae family is based on differences in the organization of the virus genome, the sequence relationship of the encoded proteins, the biological activity of the proteins, and morphological characteristics,. Virions from this family are enveloped, pleomorphic, and have a single-stranded, non-segmented, negative-sense RNA genome. Complete genomic RNA sequences for known members of the family range from 13–19 kilobases in length. The RNA consists of six to ten tandemly linked genes, of which three form the minimal polymerase complex; nucleoprotein (N or NP), phosphoprotein (P) and large polymerase protein (L). Paramyxoviruses further uniformly encode the matrix (M) and fusion (F) proteins, and – depending on virus genus – encode additional surface glycoproteins such as the attachment protein (G), hemagglutinin or hemagglutinin-neuraminidase (H, HN), short-hydrophic protein (SH) and regulatory proteins such as non-structural proteins 1 and 2 (NS1, NS2), matrix protein 2 (M2.1, M2.2), and C and V proteins,.
Routine diagnosis of paramyxovirus infections in humans and animals is generally performed by virus isolation in cell culture, molecular diagnostic tests such as reverse transcriptase polymerase chain reaction (RT-PCR) assays, and serological tests. Such tests are generally designed to be highly sensitive and specific for particular paramyxovirus species. However, to detect zoonotic, unknown, and newly emerging pathogens within the Paramyxoviridae family, these tests may be less suitable. Development of virus family-wide PCR assays has greatly facilitated the detection of previously unknown and emerging viruses. Examples of such PCR assays are available for the flaviviruses, coronaviruses, and adenoviruses. For the Paramyxoviridae, Tong et al. described semi-nested or nested PCR assays to detect members of the Paramyxovirinae or Pneumovirinae subfamily or groups of genera within the Paramyxovirinae subfamily. Although these tests are valuable for specific purposes, nesting of PCR assays and requirement for multiple primer-sets are sub-optimal for high-throughput diagnostic approaches, due to the higher risk of cross-contamination, higher cost, and being more laborious.” Here, a PCR assay is described that detects all genera of the Paramyxoviridae with a single set of primers without the requirement of nesting. This assay was shown to detect all known viruses within the Paramyxoviridae family tested. As the assay is implemented in a high-throughput format of fragment analysis, the test will be useful for the rapid identification of zoonotic and newly emerging paramyxoviruses.
The study was approved by The Medical Ethics Committee of the Instituto de Salud Carlos III. Informed written consent was obtained from parents or legal guardians.
Bats are considered a reservoir of severe emerging infectious diseases. Severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), Nipah virus, Hendra virus, and Ebola virus are all thought to be bat-borne viruses1,2.
Notably, bats also host major mammalian paramyxoviruses from the family Paramyxoviridae, order Monone-gavirales3,4. While Henipaviruses (Nipah and Hendra viruses) in South East Asia and Australia are associated with fruit bats5, other paramyxoviruses have been detected not only in fruit bats but in insectivorous bats worldwide6–9. A potential pathway for Nipah virus transmission from bats to humans was found to be associated with a human-bat interface, specifically date palm sap shared by bats and humans10. In addition, serological evidence of possible human infection with a bat-originated paramyxovirus, Tioman virus11, reinforces the epidemiological role of bats in the emergence of pathogens such as paramyxoviruses in humans.
In addition to these bat paramyxoviruses with zoonotic potential, other new paramyxoviruses have been reported. These include several new mammalian paramyxoviruses such as Beilong virus and J virus, which remain unassigned under the family Paramyxoviridae12. Recent bat-associated paramyxoviruses were proposed to be grouped in a separate phylogenetic clade within a potentially separate genus such as Shaanvirus13 which was distantly related to Jeilongvirus14. In addition, novel strains of bat paramyxoviruses in diverse genera have been reported continuously15–17. Based on the recent papers, bat paramyxoviruses found worldwide to date have belonged to the genera Rubulavirus, Morbillivirus, Henipavirus and the unclassified proposed genera Shaanvirus. Expanded classifications for grouping newly identified viruses in bats can be accomplished by further studying the biological characteristics of novel paramyxoviruses as well as genome characterization18.
In this study, active surveillance was performed to reveal paramyxoviruses circulating in Korean bats. A total of 232 bat samples were collected at 48 sites in natural bat habitats and tested for the possible existence of paramyxoviruses.
Over one-half of all known human pathogens originated from animals, and over 75% of emerging infectious diseases identified in the last three decades were zoonotic.1 The threat of veterinary pathogens to human health continues to grow because of increasing population density and urbanization, global movement of people and animals, and deforestation accompanied by increased proximity of human and wildlife habitats. Recent emerging infectious diseases have been concentrated in tropical Africa, Latin America, and Asia, with outbreaks usually occurring within populations living near wild animals.1 Identification of animal reservoirs from which zoonosis may emerge and detection and characterization of pathogens in these reservoirs will facilitate timely implementation of control strategies for new zoonotic infections.2 Therefore, pathogen discovery studies in animal reservoirs represent an integral part of public health surveillance.
Bats have long been known as natural hosts for lyssaviruses, and more recently, they have been recognized as potential reservoirs for emerging human pathogens, including henipaviruses, filoviruses, and severe acute respiratory syndrome (SARS) related coronaviruses.3,4 Novel viruses are documented in bats every year, which has drawn increasing attention to these mammalian reservoirs that are uniquely associated with a variety of known and potential zoonotic pathogens. In this study, we report the detection of nucleic acids of adenoviruses, rhabdoviruses, and paramyxoviruses in bats from Kenya.
Only Patients with viral infections were included in this study. Data extracted from the records included demographic characteristics, clinical diagnosis, immune deficiency, and number and types of viruses isolated. As this study was retrospective, it did not require ethical approval. These patients were investigated for bacterial, fungal and parasitic pathogens to rule out infection and co-infection. No bacterial, fungal and parasitic pathogens were detected in these patients.
All PIV-infected patients were immunocompetent which was defined as the absence of organ transplantation, human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), autoimmune disease, leukemia, pancytopenia, lymphoma or under immunosuppressive drug therapy. All patients underwent a respiratory virus panel screening. Respiratory system samples (bronchoalveolar lavage or tracheal aspirate) were collected in disposable mucus extractors (Vygon SA, Écouen, France). Samples were assayed by reverse transcriptase-polymerase chain reaction (RT-PCR) to detect 20 respiratory pathogen which include: influenza virus A (Flu A), influenza virus A H1N1 (H1N1), influenza virus B (Flu B), human coronavirus (HCoV)-NL63, -229E, -OC43 and HKU1, PIV-1, -2, -3, -4 human metapneumovirus (hMPV)-A and -B, rhinovirus (HRV), respiratory syncytial virus (RSV)-A and B, adenovirus (AdV), enterovirus (EV), parechovirus (HPeV), human bocavirus (HBoV), using FTD® Respiratory Pathogens kit (Fast-Track Diagnostics Ltd., Sliema, Malta).
Human metapneumovirus (HMPV), described in the Netherlands in 2001 is an RNA virus belonging to the Pneumoviridae family, genus Metapneumovirus. Two main genetic lineages A and B have been identified to date. The phylogenetic studies showed a high similarity to the respiratory syncytial virus (HRSV), with which it shares morphological and disease spectrum similarities. Upper and lower respiratory tract infections from common colds to pneumonia have been attributed to HMPV, with bronchiolitis being one of the main clinical signs of primary infection in hospitalized patients. A recent meta-analysis has provided evidence that HMPV has an important etiological role in acute lower respiratory infections in children less than five years.
Our objectives were to estimate the relative contribution of HMPV to hospitalization in children with acute respiratory tract infection in Spain and to define the clinical and epidemiological features of HMPV single and multiple infections. Also we compared HMPV infections with HRSV infections and with other common respiratory viruses over an extended period.
Viruses are the major causative agents of respiratory tract infections (RTI), but the etiology of many suspected cases of such infections remain unknown. This was the case in our previous study where 72% of the cases of RTI remained uncharacterized. Since 2001, several new human viruses have been identified in respiratory samples. These viruses were originally isolated from individuals with respiratory tract disease, most of whom were children. Accumulating data indicate that these viruses can cause both upper RTI (URTI) and lower RTI (LRTI) in children. Newly discovered viruses, such as human metapneumovirus (hMPV), human coronavirus (HCoV)-NL63, human bocavirus (Boca), human polyomavirus KI (KIV) and human polyomavirus WU (WUV) may be responsible for many respiratory tract illnesses, the cause of which has remained a mystery for decades.
The hMPV was originally isolated from the respiratory tracts of young children with respiratory disease. Since then, the virus has been identified worldwide, and many studies have demonstrated that it is a significant cause of both URTI and LRTI in infants, young children, the elderly and immunocompromised populations. The hMPV can cause severe infections, such as bronchiolitis and pneumonia, and it is responsible for 2% of the hospitalizations of children suffering from acute RTI. A study in Kuwait in 2011 indicated that the prevalence of hMPV was 5.4%.
In 2004, Fouchier et al. and van der Hoek et al. independently reported the recovery of a novel HCoV from a 7-month-old girl with coryza, conjunctivitis, fever and bronchiolitis. This virus, HCoV-NL63, is phylogenetically related to HCoV-229E. Similar to HCoV-229E, HCoV-NL63 has a worldwide distribution and has been associated with mild URTI and severe LRTI. HCoV-NL63 may be responsible for 1-10% of RTI and is associated with croup.
In 2005, Allander et al.reported the discovery of another novel human parvovirus, Boca, also isolated from respiratory specimens from children with respiratory tract disease. Since then, several studies have reported the prevalence of Boca infection worldwide as ranging from 2 to 21.5%, mainly in children younger than 3 years of age in whom the virus has been associated with URTI and LRTI. These reports suggest that Boca might be associated with upper and lower respiratory diseases throughout the world. In 2007, another two novel human polyomaviruses, KIV and WUV, were described by independent groups in Sweden and the USA. To date, preliminary data show that both KIV and WUV can be detected in up to 4.5% of respiratory samples obtained from patients with acute RTI.
In 2010 in Kuwait, Khadadah et al.screened samples for a wide range of respiratory viruses such as respiratory syncytial virus (RSV), influenza A virus (Flu A), parainfluenza virus (PIV), adenovirus (AdV), HCoV-OC43, HCoV-229E and human rhinovirus (HRV); however, 72% of the samples were negative, which suggested the potential presence of other viral etiological agents. The clinical impact of these newly discovered viruses remains unknown. The reported data clearly show that hMPV has been circulating for at least 50 years and has a definite clinical impact. In addition, there is evidence to suggest that Boca is pathogenic, but data from previous studies suggest that WUV and KIV on their own are not pathogenic. The newly discovered HCoV-OC43 and HCoV-NL63 were previously considered to be pathogenic. We aimed here to study the prevalence of the newly discovered viruses hMPV, HCoV-NL63, Boca, KIV and WUV in RTI in Kuwait.
Bovine respiratory disease complex (BRDC) is a major cause of economic losses in the cattle industry worldwide. The most important viral agent include bovine herpesvirus type 1 (BHV-1), bovine viral diarrhea virus (BVDV), bovine respiratory syncytial virus (BRSV), and bovine parainfluenza-3 virus (BPI-3V). BRSV, belonging to the genus Pneumovirus within the family Paramyxoviridae, and is one of the most important causes of lower respiratory tract infections in calves; however, adult animals with subclinical infection are the main source of infection, since reinfections are common in the herds. It is highly prevalent in cattle, with a significant economic impact as the most important viral cause of BRDC worldwide. BVDV is a Pestivirus from the family Flaviviridae, which affects the digestive, respiratory, and reproductive systems in different production animals. Clinical signs include pyrexia, diarrhea, reduced production, and highly morbid disease but cause low mortality of infected animals. Infectious bovine rhinotracheitis (IBR) is an important infectious disease of domestic and wild cattle caused by BHV-1. This virus is a member of genus Varicellovirus, which belongs to the Herpesviridae family. Clinical signs infection includes symptoms of inflammatory reactions in respiratory, genital tracts, abortion, and neurological disorders. Betancur et al. found a statistical association between seropositive animals for BHV-1 with respect sex and age in Colombia, while Ochoa et al. reported higher infection in cows older than 5 years of age. BPI-3V is in the genus Respirovirus of the family Paramyxoviridae, which cause serious economic losses in small and large ruminants. Clinical disease is usually mild, with symptoms of fever, nasal discharge, and cough. Betancur et al. reported a statistical association between seroprevalence values for BPI-3V and age groups.
Aguachica, Rio de Oro, and La Gloria municipalities are located in Cesar department, which, in turn, is located in the Northeast of Colombia, and is very important agricultural and fish raising region, being the dual-purpose cattle husbandry one of the most important agricultural components of the regional economy, with a participation of 8% in the cattle national inventory. According to the National Agricultural Institute, the state has a population of 1,305,984 heads of cattle, being 30% located in the three municipalities.
Information about the prevalence of these viral pathogens is available from several countries in which these diseases have been reported. Nevertheless, there is very little epidemiological information on viral pathogens in cattle, mainly in the Northeast region of Colombia. Therefore, the present study was conducted to estimate the seroprevalence of respiratory viral pathogens in dual-purpose cattle and evaluate risk factors in the municipalities of Aguachica, Rio de Oro, and La Gloria in the department of Cesar.
HSV is one of the leading causes of neonatal sepsis (32). In neonates, HSV can cause three types of disease: skin, eye and mouth disease, encephalitis, and disseminated disease (36). Disseminated HSV disease is the most severe form of HSV infection, with a case fatality rate of as high as 29% (29). Patients with lethargy, severe hepatic dysfunction or delayed treatment have higher mortality (29). HSV can also cause fulminant hepatitis in non-neonatal populations, typically without obvious cholestasis (37). Both disseminated HSV disease and fulminant HSV hepatitis have a clinical presentation of viral sepsis, involving hepatic dysfunction, respiratory failure, disseminated intravascular coagulopathy, and haemodynamic instability (36, 38). In the absence of skin lesions, disseminated HSV disease and HSV hepatitis are difficult to differentiate clinically from sepsis caused by other pathogens (36, 38).
Studies have reported various incidence rates of neonatal HSV infection, ranging from 8 to 60 per 100,000 live births, with disseminated HSV disease accounting for 25% of cases (39). Some viral factors are associated with viral sepsis. Firstly, a large inoculum of HSV may increase the risk of viral sepsis (38). Secondly, it has been shown that maternal genital HSV type 1 (HSV-1) infection has a higher probability of transmission to neonates during labour than HSV type 2 (HSV-2) infection (40). However, HSV-2 accounts for a higher proportion of neonatal central nervous system (CNS) and disseminated HSV diseases although HSV-1 causes about 60% of cases of neonatal HSV infection (41). This also explains why HSV-2 is associated with higher morbidity and mortality (39). Furthermore, neonates born to mothers with newly-acquired genital HSV infection near term are at greater risk for neonatal HSV infection than those born to mothers with reactivated genital HSV infection (42).
Viral infections are ubiquitous and are common in patients admitted to intensive care unit (ICU) and pediatric intensive care unit (PICU) and may be associated with significant morbidity and mortality. The vast majority of scientific articles dealing with infections address bacterial or fungal infections, and viral agents are often disregarded. Despite their prevalence, viral infections are frequently not considered to be of clinical significance among the critically ill patients, unless the patient is immunocompromised. Among immunocompetent critically ill patients, viral infections can lead to a significant morbidity and mortality.
Parainfluenza viruses (PIV) were first discovered in 1950. They are enveloped non-segmented, negative single-stranded RNA viruses. PIV are genetically and antigenically divided into four types: PIV-1, PIV-2, PIV-3 and PIV-4, each with different genetic and antigenic features. PIV are a cause of community-acquired pneumonia in healthy individuals and can infect individuals of any age group [4–6]. The majority of PIV-infected patients are treated in outpatient clinics, yet PIV infections are one of the most common causes of respiratory diseases leading to hospitalization [4, 5, 7]. Among the immunocompromised patients, PIV especially type 3 has been associated with serious outcomes and complications. PIV can also be clinically significant in ICU and PICU patients [9, 10]. However, not much is known about the burden of PIV infections among ICU and PICU patients. Such data are essential because they could shed light on the importance of these infections and could help researchers and public health officials determine the need for new vaccines and effective antiviral drugs. Until now, no specific antiviral drugs or effective vaccine are available despite the progress made in these fields recently [11–13]. The aim of this study was to evaluate the possible effect of PIV infections on ICU and PICU patients in Kuwait, in addition to defining the clinical features of PIV infections among these patients over a 3-year period.
Human parainfluenza viruses (HPIVs) are members of the family Paramyxoviridae and circulate globally as four species. They are classified into two genera based on their genome, HPIV1 and HPIV3 as genus Respirovirus, and HPIV2 and HPIV4 as genus Rubulavirus1.
HPIV infection can manifest as both acute upper respiratory infections (AURI) and acute lower respiratory infections (ALRI)2. Although HPIV infections are generally self-limiting, they occasionally require hospitalization and may lead to mortality. Infections with HPIV are second only to respiratory syncytial virus (RSV) as a cause of ALRI-associated hospitalization in children under the age of five years3.
Specific clinical diagnoses have been attributed to individual HPIV species, e.g. HPIV1 and HPIV2 infection with laryngotracheobronchitis (croup) and HPIV3 with bronchiolitis. These clinical associations, however, are neither predictive of a certain HPIV species nor mutually exclusive. Low- and middle-income countries have a high burden of disease due to severe ALRI with the highest number of HPIV infections among young children. High-risk populations include individuals with chronic respiratory conditions, prematurely-born infants, and the immunosuppressed. HPIV3, in particular, infects younger children after waning of maternal antibodies4. Nonetheless, country-specific descriptions of clinical profiles for individual HPIV species are largely lacking5. Clinical severity has been attributed to the ability of the virus to efficiently replicate in the upper respiratory tract prior to spread to the lower respiratory tract2,6. Whereas the majority of HPIV infections occurs in children, these viruses can infect individuals from all age groups. Consequently, they likely form one gene pool with endemic circulation across all ages.
Factors contributing to successful transmission include shedding of the virus at sufficiently high titers, from the upper respiratory tract, environmental stability of the virion and ability to initiate infection upon contact with a new host. HPIVs replicate abundantly in the tracheal epithelium facilitating transmission from the upper respiratory tract and are likely highly infectious, as was demonstrated for a closely related murine virus7,8. Transmission of HPIVs is by close contact and short-range transmission by respiratory droplets with minimal aerosol transmission9. HPIV also retains its infectivity on inanimate objects for up to 10 hours10 and its incubation period as found in volunteer studies was estimated at 3–6 days11. No specific antivirals or vaccines to treat and prevent HPIV infection are currently available.
Periodicity and magnitude of HPIV epidemics is likely determined by susceptibility to infection, partial cross-protective immunity and differences in virus transmissibility12–15. Disease presentation and severity varies between HPIV species, geographic locations and over time16. However, our understanding of the molecular epidemiology and global transmission of HPIV is limited since sequence information to date is mainly restricted to the hemagglutinin-neuraminidase (HN) gene, while full genome data is sparse and biased towards the Americas.
The present study describes species-specific clinical presentation, the genetic variability and HPIV circulation in Viet Nam. The outcome of RSV infection in hospitalized children under 2 years of age presenting with acute lower respiratory infection (ALRI) in Ho Chi Minh City was described previously17. A second study was conducted enrolling children under 16 years of age presenting with acute respiratory infection (ARI) to outpatient departments. Respiratory samples from both cohorts that were positive for HPIV were sourced into the current study for sequencing purposes. Using Bayesian phylogenetic methods, we also infer the importation of HPIV into Viet Nam from viral sequence data and report high viral diversity within the country.
Viral meningoencephalitis due to a prolonged infection with enterovirus is strongly suggestive of a specific class of PIDD. Enteroviruses are the most common cause of viral meningitis in the general population manifesting as acute onset headache with gradual resolution over days to a few weeks. In patients with agammaglobulinemia, manifestations are quite different (124). These children typically present with regression of developmental milestones. Ataxia or clumsiness may be noted by parents or on examination. Features early on are subtle, and the slow progression can lead to efforts at mitigation with physical therapy or behavioral strategies. In a patient with a known humoral immune deficiency, the index of suspicion should be high and a workup should not be delayed if there are clear neurologic signs or symptoms. CNS infection in patients with agammaglobulinemia has a very poor prognosis. There can be other phenotypes associated with enteroviral disease in patients with agammaglobulinemia; however, CNS infection is the most common. Dermatomyositis and hepatitis have been described and have progressed in some cases to CNS infection. Treatment for enteroviral disease includes high dose immunoglobulin and when available, drugs directed at enterovirus.
A unique subset of CNS enteroviral infections occurs in either SCID or agammaglobulinemia with live-attenuated polio vaccine. Wild-type polio, occurring in three serotypes, has been nearly eradicated. Even early on, it was recognized that the live-attenuated vaccine could cause disease (125) and that patients with hypogammaglobulinemia could excrete virus for years (126, 127). Currently, circulating wild-type polio is seen only in Afghanistan and Pakistan although virus can be isolated in sewage from other countries supporting ongoing risk for immunodeficient individuals (128). Vaccine-associated poliomyelitis can be due to infection of an immune deficient individual and spread to the CNS or to revertants of vaccine-strain virus (129, 130). In the latter case, even normal hosts can have overt paralytic disease. Vaccine-associated poliomyelitis can appear as acute flaccid paralysis or with a meningoencephalitis in immunodeficient individuals. The prognosis has generally been poor (131).
Testing for defects related to herpes simplex encephalitis often involves genetic sequencing although functional analyses are available on a research basis. Table 3 lists the currently recognized genetic causes of susceptibility to herpes simplex encephalitis.
The diagnosis of enteroviral meningoencephalitis in PIDD patients requires a specific description. In a patient with agammaglobulinemia detection of enterovirus is surprisingly difficult. PCR analysis of cerebrospinal fluid or stool (less specific) should be performed. However, it is not unusual for children with agammaglobulinemia and suggestive clinical features to require a brain biopsy for diagnosis. The biopsy tissue can be tested for enterovirus by PCR. In a patient who presents with CNS enteroviral disease, identification of an immune deficiency is critical because of the prognostic implications. The strong association of CNS enteroviral disease with agammaglobulinemia supports a strategy that begins with enumeration of peripheral blood B cells by flow cytometry. Only if that is negative and there are no other secondary immune deficiencies should alternatives such as CD40L or CVID be sought. A reasonable secondary screen would be to measure immunoglobulin levels and responses to vaccines.
Viral Respiratory tract infections (RTI) represent a major public health problem because of their world-wide occurrence, ease of transmission and considerable morbidity and mortality effecting people of all ages. Children are on average infected two to three times more frequently than adults, with acute RTIs being the most common infection in childhood. Illnesses caused by respiratory viruses include, among others, common colds, pharyngitis, croup, bronchiolitis, viral pneumonia and otitis media. Rapid diagnosis is important not only for timely therapeutic intervention but also for the identification of a beginning influenza epidemic and the avoidance of unnecessary antibiotic treatment.
RTIs are a major cause of morbidity and mortality worldwide. Acute RTI is most common in children under five years of age, and represents 30–50% of the paediatric medical admissions, as well as 20–40% of hospitalizations in children. Respiratory infections cluster during winter and early spring months. The leading viral agents include respiratory syncytial virus (RSV), influenza A and B (INF-A, INF-B) viruses, parainfluenza viruses (PIVs), and human adenoviruses (HAdVs). In addition, there is a continuously increasing list of new respiratory viruses that contribute significantly to the burden of acute respiratory infections, such as the recently identified human metapneumovirus (HMPV) and human Bocavirus (HBoV).
Acute RTIs are classified as upper (UTRIs) and lower RTI (LRTIs), according to the involved anatomic localization. URTIs cause non-severe but widespread epidemics that are responsible for continuous circulation of pathogens in the community. LRTIs have been classified as frank pneumonia and bronchiolitis with clinical, radiological and etiological features that usually overlap. Viruses are again the foremost agents of LRTIs often misdiagnosed as bacterial in origin and hence treated with antibiotics unnecessarily.
The main aim of this study was to determine the aetiology of acute respiratory tract infections in Cypriot children and assess the epidemiology of the identified viral pathogens over three epidemic seasons.
Nucleic acid isolation and multiplex PCR were performed for respiratory viruses such as Flu A, PIV-1, PIV-2, PIV-3, RSV, HCoV-OC43, HCoV-229E and HRV as previously described.
Domestic rabbit (Oryctolagus cuniculus), especially New Zealand white rabbit, has attracted more and more attention in biomedical, immunological and pharmaceutical research, because of its intermediate size and phylogenetic proximity to primates. It played an important role in production of antibodies, eye research as well as cardiovascular disease [2, 3]. Rabbit is one of the most commonly used experimental animals and must be free of some important pathogens.
The first outbreak of rabbit hemorrhagic disease (RHD) caused by the rabbit hemorrhagic disease virus (RHDV) occurred in 1984 in Jiangsu Province, China and spread all around the world rapidly. It’s an acute and mostly fatal contagion in both domestic and wild rabbits, characterized by acute necrotizing hepatitis and hemorrhage. Actually there are three different clinical features, the pre-acute, acute and sub-acute forms. Among which the sub-acute form causes no clinical symptoms and rabbits will recover within 2~ 3 days. Rabbit rotavirus (RRV) infection was the major cause of mild to severe diarrhea in rabbits. The rotavirus isolated from infected rabbits belongs to Group A rotaviruses (RVAs), which also infect humans and other animals. It’s a highly contagious mild virus and disseminated by fecal-oral route [9–11]. Although the infection rate of RRV is high, most infections are subclinical. However, co-infection with other bacteria or viruses may cause severe enteritis and the excretion by the infected rabbits will become the contaminate source and cause new infection. Sendai virus (SV), also known as a murine parainfluenza virus type 1, belongs to Respirovirus, Paramyxoviridae family. It causes transmitted respiratory tract infections in a variety of animals. Unlike rodents, rabbits are not sensitive to SV, and the infection will only cause fever but not respiratory tract contagious in rabbits.
Despite the asymptomatic infection and low mortality of rotavirus and Sendai virus infection, the existence of these two viruses will affect the quality of experimental animals and severely interfere with the results of animal experiments on them. To improve the quality of rabbits and ensure the accuracy of animal experiments, RHDV, SV and RRV are the required inspection items ruled by the national quality standard of China.
The traditional methods for pathogen identification include etiology diagnosis, serological diagnosis as well as molecular diagnosis [14, 15]. According to the laboratory animal microbiological quality control standards of China, the recommended test methods for these viruses mainly are the etiology and serological diagnosis. Both of them are time-consuming and laborious, compared with molecular diagnostic techniques. Polymerase chain reaction (PCR) with high sensitivity and specificity is widely used in pathogeny identification [16, 17]. Reverse transcription-PCR (RT-PCR) and quantitative reverse transcription-PCR (RT-qPCR) assays had been developed for monitoring of rabbit hemorrhagic disease virus, Sendai virus as well as rabbit rotavirus [18–20]. However, the restricted throughput limited the application of PCR, even the multiplex real-time quantitative PCR could not detect more than five pathogens in one reaction. The development of rapid and sensitive multiplex diagnostic method was extremely important for rabbit health monitoring. Compared with conventional PCR methods, the Luminex technology was a high-throughput, rapid, sensitive and labor-saving multiplex assay. Conjugation of microbeads with different fluorescent dyes could differentiate as much as 100 targets in a single reaction. This technology offered a variety of applications in pathologic diagnosis [22–24].
In this study, we developed a multiplex PCR-based MagPlex-TAG assay for simultaneous detection of rabbit hemorrhagic disease virus, rabbit rotavirus and Sendai virus.
Paramyxoviridae is a large and diverse family whose members have been isolated from many species of avian, terrestrial, and aquatic animal species around the world. Paramyxoviruses are pleomorphic, enveloped, cytoplasmic viruses that have a non-segmented, negative-sense RNA genome. The family is divided into two subfamilies, Paramyxovirinae and Pneumovirinae, based on their structure, genome organization, and sequence relatedness. The subfamily Paramyxovirinae contains five genera: Respirovirus, Rubulavirus, Morbillivirus, Henipavirus, and Avulavirus, while the subfamily Pneumovirinae contains two genera, Pneumovirus and Metapneumovirus. All paramyxoviruses that have been isolated to date from avian species can be segregated into two genera based on the taxonomic criteria mentioned above: genus Avulavirus, whose members are called the avian paramyxoviruses (APMV), and genus Metapneumovirus, whose members are called avian metapneumoviruses. The APMV of genus Avulavirus are separated into nine serotypes (APMV-1 through -9) based on Hemagglutination Inhibition (HI) and Neuraminidase Inhibition (NI) assays. Various strains of APMV-1, which is also called Newcastle disease virus (NDV), have been analyzed in detail by biochemical analysis, genome sequencing, and pathogenesis studies, and important molecular determinants of virulence have been identified. As a first step in characterizing the other APMV serotypes, complete genome sequences of one or more representative strains of APMV serotypes 2 to 9 were recently determined, expanding our knowledge about these viruses.
APMV-1 comprises all strains of NDV and is the best characterized serotype because of the severity of disease caused by virulent NDV strains in chickens. NDV strains vary greatly in their pathogenicity to chickens and are grouped into three pathotypes: highly virulent (velogenic) strains, which cause severe respiratory and neurological disease in chickens; moderately virulent (mesogenic) strains, which cause mild disease; and non-pathogenic (lentogenic) strains, which cause inapparent infections. In contrast, very little is known about the comparative disease potential of APMV-2 to APMV-9 in domestic and wild birds. APMV-2 strains have been isolated from chickens, turkeys and wild birds across the globe. APMV-2 infections in turkeys have been found to cause mild respiratory disease, decreases in egg production, and infertility. APMV-3 strains have been isolated from wild and domestic birds. APMV-3 infections have been associated with encephalitis and high mortality in caged birds. APMV-4 strains have been isolated from chickens, ducks and geese. Experimental infection of chickens with APMV-4 resulted in mild interstitial pneumonia and catarrhal tracheitis. APMV-5 strains have only been isolated from budgerigars (Melopsittacus undulatus) and cause depression, dyspnoea, diarrhea, torticollis, and acute fatal enteritis in immature budgerigars, leading to very high mortality. APMV-6 was first isolated from a domestic duck and was found to cause mild respiratory disease and drop in egg production in turkeys, but was avirulent in chickens. APMV-7 was first isolated from a hunter-killed dove and has also been isolated from a natural outbreak of respiratory disease in turkeys. APMV-7 infection in turkeys caused respiratory disease, mild multifocal nodular lymphocytic airsacculitis, and decreased egg production. APMV-8 was isolated from a goose and a feral pintail duck. APMV-9 strains have been isolated from ducks around the world. APMV types -2, -3, and -7 have been associated with mild respiratory disease and egg production problems in domestic chickens. There are no reports of isolation of APMV-5, -8 and -9 from poultry. But recent serosurveillance of commercial poultry farms in USA indicated the possible prevalence of all APMV serotypes excluding APMV-5 in chickens.
APMV-1 (NDV) is known to replicate in non-avian species including humans, although its only natural hosts are birds. APMV-1 infections in non-avian species are usually asymptomatic or mild. Clinical signs in human infections commonly involve conjunctivitis, which usually is transient and self-limiting. Presently, APMV-1 is being evaluated as a vaccine vector against human pathogens. When administered to the respiratory tract of non-human primates, NDV is highly restricted in replication, but foreign antigens expressed by recombinant NDV vectors are moderately to highly immunogenic. One of the major advantages of this approach is that most humans do not have pre-existing immunity to APMV-1. Pre-existing immunity is a potential drawback to using vectors derived from common human pathogens, and also can be a concern for any vector if two or more doses are necessary to elicit protective immunity. Therefore, we are investigating APMV types 2 to 9, which are antigenically distinct from APMV-1, as alternative human vaccine vectors. Also, some of these additional APMV types likely will have differences in replication, attenuation, and immunogenicity compared to APMV-1 that may be advantageous. However, the replication and pathogenicity of APMV-2 to -9 in non-avian species has not been studied. As a first step, we have evaluated the replication and pathogenicity of APMV-2 to -9 in hamsters. In this study, groups of hamsters were infected with a prototype strain of each APMV serotype by the intranasal route and monitored for virus replication, clinical symptoms, histopathology, and seroconversion. Our results showed that each of the APMV serotypes replicated in hamsters without causing adverse clinical signs of illness, although histopathologic evidence of disease was observed in some cases, and also induced high neutralizing antibody titers.
HPeVs are also frequently associated with sepsis in paediatric and immunodeficient populations. HPeVs have previously been defined as a subset of the genus Enterovirus but were eventually re-classified as their own genus of viruses after sequencing revealed them to be unrelated to enterovirus. Antibodies against HPeVs are present in the cerebrospinal fluid (CSF) of up to 99% of the population (52), with HPeV type 3 (HPeV3) (the most common cause of HPeV sepsis) being present in 10% of the population studied in the Netherlands and 13% in Finland (52). HPeVs are the second most common cause of viral sepsis in young children after enteroviral infections (33). HPeV infections are often asymptomatic or present with very mild symptoms, although severe infections can have symptoms ranging from sepsis and sepsis-like illnesses to viral meningitis and encephalitis (33). White matter abnormalities on magnetic resonance imaging have been found in cases of HPeV encephalitis, which may play a role in the development of sequelae (53–55). The development of white matter abnormalities and sequelae seems to show little association with short term outcomes (54). Clinical presentations of HPeV infections are similar to those of enteroviral infections, are clinically indistinguishable and require serology or PCR to discriminate between them. HPeV3 is the HPeV most commonly associated with severe disease, with other HPeVs known to cause severe disease only rarely (56, 57).
Licensed specific antiviral therapy is not available for HPeV or enterovirus infections, despite their relatively high incidence in neonatal encephalitis and systemic infections (58). This presents a promising target for future research, and a tangible way to reduce the incidence of neonatal viral sepsis and associated infant mortality globally.
The addition of a PCR test for HPeVs to the re-analysis of 761 banked CSF samples from children presenting with sepsis found a 31% increase in detection of a viral cause of sepsis in these cases (33), with HPeV being found in 0.4–8.2% of neonates presenting with sepsis, depending on the year, with an overall detection rate of 4.6%. It is thus likely that viral sepsis caused by HPeVs is frequently underdiagnosed.
EV-D68 preferentially causes severe respiratory symptoms in children and adults that have a prior history of asthma. Thus, in addition to naïve mice, HDM-sensitized and -challenged mice also been studied. In mice with allergic airways disease, EV-D68 enhances allergen-induced type 2 inflammation with increased expression of lung IL-5, IL-13 and Muc5ac and augmentation of bronchoalveolar lavage fluid eosinophils and airway responsiveness.
Bovine respiratory disease complex (BRDC) is a major problem for cattle breeders worldwide, causing serious economic losses. BRDC is associated with infection by certain viruses, bacteria, and parasites (33). In addition to these infectious agents, stress factors such as transport, gestation, and poor management conditions play an important role in the onset of the disease (30). Bovine herpes virus 1 (BHV-1), bovine respiratory syncytial virus (BRSV), and bovine parainfluenza virus-3 (BPIV3) are the most common viral agents of the respiratory system. Some opportunistic agents (Mannheimia haemolytica, Pasteurella multocida, Haemophilus somnus, and Mycoplasma spp.) contribute to the appearance of clinical signs and thus increase mortality and cause losses in the herds (18). Suppressed immunity also has an important role in the prognosis. Diseases such as bovine leucosis and bovine viral diarrhoea suppress immunity and lead to more animal loss by worsening clinical symptoms.
BPIV3 (the new name of which is bovine respirovirus 3) is an RNA virus assigned to the Paramyxoviridae family under the Respirovirus genus. BRSV (the new name of which is bovine orthopneumovirus) is in the Pneumoviridae family under the Orthopneumovirus genus. To date, three genotypes of BPIV3 have been described. These genotypes, termed A, B, and C, were differentiated based on phylogenetic analysis. Genotype A strains have been isolated in North America, China, and Japan. Genotype B was originally found in Australia. Isolations of genotype C were in China, South Korea, and Japan. In addition, all three genotypes have been reported in Argentina (23).
Initially BRSV subgroups were identified (A, B, and AB or intermediary) based on monoclonal antibody and polyclonal sera analyses against F and G proteins (31). Additionally, Valarcher et al. (36) proposed that six genetic subgroups may be found in BRSV strains, when F, G, and nucleoprotein sequences are phylogenetically analysed by maximum-likelihood algorithms. Therefore, six subgroups were detected in BRSV. These subgroups termed I (the subgroup B prior to the recommendation of Valarcher et al. (36)), III (subgroup A), and II, IV, V, and VI (subgroup AB) were differentiated based on phylogenetic analysis. Subgroup I consists of European strains (UK and Switzerland). Subgroup III includes viruses exclusively from the USA. Subgroup II aggregates strains from the Netherlands, Belgium, France, Denmark, Sweden, and Japan. Subgroup IV is of European and USA strains while subgroups V and VI are found only in French and Belgian isolates (29, 36). Subgroup VII was detected in later years (9) and some strains are known which are still not classified (these are regarded as untyped) (10).
BPIV3 and BRSV can cause mild symptoms or subclinical disease when present alone. However, when there is a co-infection, they may cause bronchopneumonia, severe cough, high fever, and nasal discharge and contribute to a more serious clinical course of infection (33). Regardless of the infecting agent in BRDC, clinical symptoms may be similar and the process of detecting the underlying primal agent may be hindered due to mixed bacterial infections. This situation makes viral diagnosis difficult and decreases the specificity and sensitivity of the molecular methods (when compared to immunofluorescence antibody tests) (15).
Data on virological detection of these agents in Turkey is limited (2, 6), but there are more studies on seroprevalence of these viruses among cattle herds. The studies reported lowest and highest seropositivity of 11% (1) and 92.8% (13) for BPIV3 and 28% (1) and 94% (13) for BRSV. Serological studies on BRSV and BPIV3 were previously conducted in different geographic regions of our country. In these studies the following percentage values for BRSV and BPIV3 prevalence were determined respectively: Alpay et al. (5) 26.6% and 44.6%, Alkan et al. (3) 62.0% and 44.6%, Avci et al. (7) 78.2% and 85.6%, Çabalar and Can Sahna (11) 67.3% and 18%, Yavru et al. (40) 46% and 53.9%, and Yesilbag and Gungor (41) 73.0% and 43%. These studies were conducted either countrywide (3) or in selected regions (40, 41).
The aim of this study was the detection and molecular characterisation of BPIV3 and BRSV strains retrieved from nasal swabs and lung samples of cows in the eastern region of Turkey. The determination of BRSV and BPIV3 types and associated co-infections for respiratory system infections was conducted.